The nurse is performing a psychosocial assessment on a client with severe rheumatoid arthritis. What would be the most appropriate statement by the nurse?

"Tell me about what medications you are taking."

"What physical limitations are you experiencing?"

"How does this impact your role in your family?"

"What therapies are you using to reduce swelling?"

Answer and Explanation

The Correct Answer is C

Choice A reason: "Tell me about what medications you are taking." is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Medications are part of the physical or pharmacological assessment, which focuses on the type, dose, frequency, and effectiveness of the drugs that the client is taking for rheumatoid arthritis. Medications may have some psychosocial implications, such as side effects, costs, or adherence, but they are not the main focus of the psychosocial assessment.

Choice B reason: "What physical limitations are you experiencing?" is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Physical limitations are part of the functional or mobility assessment, which focuses on the range of motion, strength, endurance, and coordination of the joints and muscles that are affected by rheumatoid arthritis. Physical limitations may have some psychosocial implications, such as pain, disability, or dependence, but they are not the main focus of the psychosocial assessment.

Choice C reason: "How does this impact your role in your family?" is the most appropriate statement by the nurse, because it is related to the psychosocial assessment. Role in the family is part of the social or relational assessment, which focuses on the interactions, responsibilities, and expectations of the client and their family members in relation to rheumatoid arthritis. Role in the family may have significant psychosocial implications, such as role changes, role conflicts, role strain, or role loss, which can affect the client's selfesteem, identity, and coping.

Choice D reason: "What therapies are you using to reduce swelling?" is not the most appropriate statement by the nurse, because it is not related to the psychosocial assessment. Therapies are part of the physical or nonpharmacological assessment, which focuses on the modalities, techniques, or devices that the client is using to manage the symptoms of rheumatoid arthritis. Therapies may have some psychosocial implications, such as availability, accessibility, or preference, but they are not the main focus of the psychosocial assessment.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

Choice A reason: Ischemia is a cause of a pressure ulcer, because it means reduced blood flow to the tissues, which can lead to tissue hypoxia, necrosis, and ulceration. Ischemia can result from factors such as compression, friction, shear, or vascular disease.

Choice B reason: Immobility is a cause of a pressure ulcer, because it means prolonged pressure on the bony prominences, which can impair blood flow and cause ischemia, tissue damage, and ulceration. Immobility can result from factors such as paralysis, injury, illness, or sedation.

Choice C reason: Poor nutrition is a cause of a pressure ulcer, because it means inadequate intake or absorption of nutrients, such as protein, calories, vitamins, and minerals, which are essential for tissue repair and wound healing. Poor nutrition can result from factors such as anorexia, malabsorption, or poverty.

Choice D reason: Moisture is a cause of a pressure ulcer, because it means excessive wetness or dampness of the skin, which can weaken the skin barrier, increase the risk of infection, and delay wound healing. Moisture can result from factors such as incontinence, perspiration, or wound drainage.

Choice E reason: Adequate perfusion is not a cause of a pressure ulcer, but rather a protective factor. Adequate perfusion means sufficient blood flow to the tissues, which can prevent ischemia, tissue damage, and ulceration. Adequate perfusion can be promoted by factors such as regular repositioning, pressure relief, and exercise.

A. Client will remain free from falls throughout their hospital stay. B. Client will increase activity tolerance by discharge from the hospital. C. Client will demonstrate effective breathing pattern when ambulating throughout hospital stay. D. Client will increase mobility by the time of discharge from hospital.

Correct Answer is A

Explanation

Choice A reason: Client will remain free from falls throughout their hospital stay is the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is specific, measurable, attainable, realistic, and timely. This goal addresses the main risk factor for injury, which is falling, and the main outcome indicator, which is the absence of falls. This goal also reflects the client's condition, needs, and preferences, and is consistent with the standards of care and evidencebased practice.

Choice B reason: Client will increase activity tolerance by discharge from the hospital is not the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is vague, subjective, unachievable, unrealistic, and untimely. This goal does not address the main risk factor for injury, which is falling, nor the main outcome indicator, which is the absence of falls. This goal also does not reflect the client's condition, needs, and preferences, and is not consistent with the standards of care and evidencebased practice.

Choice C reason: Client will demonstrate effective breathing pattern when ambulating throughout hospital stay is not the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is irrelevant, unrelated, unnecessary, unrealistic, and untimely. This goal does not address the main risk factor for injury, which is falling, nor the main outcome indicator, which is the absence of falls. This goal also does not reflect the client's condition, needs, and preferences, and is not consistent with the standards of care and evidencebased practice.

Choice D reason: Client will increase mobility by the time of discharge from hospital is not the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery, because it is vague, subjective, unachievable, unrealistic, and untimely. This goal does not address the main risk factor for injury, which is falling, nor the main outcome indicator, which is the absence of falls. This goal also does not reflect the client's condition, needs, and preferences, and is not consistent with the standards of care and evidencebased practice.

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The nurse is performing a psychosocial assessment on a client with severe rheumatoid arthritis. What would be the most appropriate statement by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

What are the causes of a pressure ulcer? (Select all that apply.)

Correct Answer is ["A","B","C","D"]

Explanation

Which of the following would be the most appropriate goal for an elderly client with a nursing diagnosis of risk for injury after hip surgery?

Correct Answer is A

Explanation

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