This is the edited text:
What is not an expected assessment finding in a client with inflammation? (Select all that apply.)
Polyuria
Edema
Heat
Erythema
Pain
Correct Answer : A,B
Choice A reason: Polyuria is the production of abnormally large amounts of urine, which can be caused by various factors, such as diabetes, kidney disease, or diuretics. Polyuria is not an expected finding in a client with inflammation, which is the body's response to injury or infection. Inflammation does not affect the urinary system directly, unless the inflammation is located in the kidneys or bladder.
Choice B reason: Edema is the swelling of tissues due to excess fluid accumulation, which can be caused by various factors, such as heart failure, liver disease, or venous insufficiency. Edema is not an expected finding in a client with inflammation, which is the body's response to injury or infection. Inflammation does not cause fluid retention, but rather fluid leakage from the blood vessels into the interstitial spaces.
Choice C reason: Heat is an expected finding in a client with inflammation, which is the body's response to injury or infection. Heat is caused by the increased blood flow to the inflamed area, which brings more oxygen and nutrients to the damaged tissues. Heat also helps to kill or inhibit the growth of microorganisms that may cause infection.
Choice D reason: Erythema is an expected finding in a client with inflammation, which is the body's response to injury or infection. Erythema is the redness of the skin due to the dilation of the blood vessels in the inflamed area, which increases the blood flow and the delivery of oxygen and nutrients to the damaged tissues. Erythema also helps to signal the presence of inflammation and attract immune cells to the site.
Choice E reason: Pain is an expected finding in a client with inflammation, which is the body's response to injury or infection. Pain is caused by the stimulation of the nerve endings by chemical mediators, such as histamine, prostaglandins, and bradykinin, that are released by the inflamed tissues. Pain also helps to alert the client of the injury or infection and to limit the movement or use of the affected area.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
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.
Correct Answer is D
Explanation
Choice A reason: This is an unrealistic and unattainable goal for a client with rheumatoid arthritis. Rheumatoid arthritis is a chronic and progressive inflammatory disease that causes joint pain, stiffness, swelling, and deformity. It is not possible to eliminate pain completely with this condition. The nurse should help the client set realistic and individualized goals for pain management.
Choice B reason: This is a vague and subjective goal for pain control. Pain is a personal and multidimensional experience that varies from person to person. The nurse should use a valid and reliable pain assessment tool, such as the numeric rating scale, to measure the client's pain intensity and quality. The nurse should also ask the client about their acceptable level of pain and how it affects their daily activities and quality of life.
Choice C reason: This is a good goal for general health and wellness, but it is not specific to pain control. Eating healthy meals and staying hydrated can help the client maintain their nutritional status and hydration, which are important for overall health. However, they do not directly address the pain caused by rheumatoid arthritis. The nurse should also consider other factors that can influence pain, such as stress, mood, sleep, and coping strategies.
Choice D reason: This is the best goal for pain control in a client with rheumatoid arthritis. It is realistic, measurable, and individualized. It acknowledges that some pain is inevitable with this condition, but it aims to reduce it to a tolerable level that allows the client to function and enjoy life. It also uses a numeric rating scale to quantify the pain and monitor the effectiveness of interventions.
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