Exhibits
The healthcare provider (HCP) is reviewing the client's laboratory results and imaging and has diagnosed the client with rheumatoid arthritis.
Drag from Word Choices to complete the sentence.
Due to the new diagnosis of rheumatoid arthritis, the nurse should recognize that the client is at risk for
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}
Rationale for Correct Choices:
- Impaired physical mobility: Rheumatoid arthritis leads to joint inflammation, stiffness, and potential deformities. These symptoms may result in decreased range of motion and difficulty with physical movements, contributing to impaired mobility.
- Acute pain: RA causes acute inflammation in the joints, resulting in pain, especially during flare-ups. The client experiences pain and stiffness in the hands and wrists, which aligns with the acute pain risk associated with RA.
- Knowledge deficit: Newly diagnosed RA patients often lack understanding about the disease process, treatment options, and lifestyle modifications. The nurse needs to recognize that the client requires education to manage their condition effectively and understand the long-term implications.
Rationale for Incorrect Choices:
- Electrolyte imbalance: Electrolyte imbalances are not a typical complication of rheumatoid arthritis. While certain medications used to treat RA (like corticosteroids) can impact electrolyte levels, this is not an immediate concern or a direct risk associated with RA itself.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","E","F"]
Explanation
A. Oxygen saturation 95% on room air A SpO2 of 95% is within acceptable limits, especially in a client who is not exhibiting signs of respiratory distress. This does not require immediate investigation, as it is not low enough to be concerning.
B. Bone misalignment: The client’s collarbone appears out of alignment on the left side. This could indicate a fracture or dislocation that needs to be evaluated further to prevent further injury, ensure proper alignment, and determine the need for stabilization or surgical intervention.
C. Swelling at the site of injury: Swelling at the injury site, especially with a history of trauma, could indicate a fracture or soft tissue damage. The nurse should assess the extent of the swelling to rule out internal bleeding, compartment syndrome, or a fracture requiring urgent management.
D. Nausea and fatigue reported by client: Nausea and fatigue can be symptoms of more serious conditions, such as a concussion or internal bleeding, especially given the trauma to the head. These symptoms should be investigated to rule out any neurological or systemic involvement.
E. Decreased range of motion: The client’s decreased range of motion in the left arm, particularly with the reported intense pain, indicates a potential fracture, dislocation, or significant soft tissue injury. This needs to be further assessed to ensure proper treatment and avoid further complications.
F. Intense pain reported by client: The client reports intense pain (10 on a 0 to 10 scale) in the left arm, along with difficulty moving it. This is a critical symptom, suggesting a possible fracture, dislocation, or soft tissue injury that needs to be addressed immediately.
G. Left arm that is cool to touch: Coolness to the touch in the left arm could indicate a lack of adequate blood circulation, potentially from vascular injury or compression. This requires further evaluation to assess for possible arterial injury or compartment syndrome.
G. Blood pressure of 136/90 mm Hg: While 136/90 mm Hg is elevated for a general population, it is not an immediate life-threatening concern in this acute trauma setting. It could be a normal finding for someone with a history of hypertension, or a temporary elevation due to pain and anxiety from the injury.
Correct Answer is B
Explanation
A. Advise the UAP to document the last blood pressure obtained on the client's graphic sheet: Documenting a previous reading does not reflect the client’s current condition and can be misleading in decision-making. Vital signs should be based on real-time assessment.
B. Demonstrate how to palpate the popliteal pulse with the client supine and the knee flexed: The popliteal site is appropriate for measuring blood pressure when the arms are inaccessible. Flexing the knee while the client is supine allows better access to the artery and enables accurate assessment of blood pressure in this situation.
C. Document why the blood pressure cannot be accurately measured at the present time: While documentation is necessary if no alternative is available, the nurse must first exhaust appropriate options for obtaining a blood pressure before choosing to omit it.
D. Estimate the blood pressure by assessing the pulse volume of the client's radial pulses: Pulse volume gives a very rough estimate of perfusion but does not provide an accurate or objective blood pressure measurement. This method lacks precision.
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