A client admitted with thyrotoxicosis is reporting a "pounding heart in the chest." Which assessment finding warrants immediate intervention by the nurse?

A. RA often causes joint pain and stiffness, which can make it challenging to complete daily activities. Teaching the client how to set priorities and pace their activities helps them balance exertion with rest, thus reducing fatigue and improving overall function. This approach supports effective management of their condition by preventing overexertion and allowing time for recovery.
B. While rest is important for managing fatigue, strict bedrest is generally not recommended for RA patients. Prolonged bedrest can lead to muscle weakness, joint stiffness, and decreased mobility. Active management through appropriate rest and activity is usually more beneficial than complete bedrest.
C. Transferring to an assisted living center may be appropriate for some clients, but this intervention is not necessarily related to managing fatigue due to rheumatoid arthritis in the current context. This
decision would typically depend on the overall level of care needed and the client’s living situation.
D. While providing reassurance is part of supportive care, it’s important to address the specific needs and management strategies for fatigue. Simply offering assurance without practical interventions may not effectively address the client’s current symptoms or help them manage their condition in the long
term.

Potential Condition
Poor healing of stage 2 pressure injury
The stage 2 pressure injury on the right trochanter with minimal drainage and pain suggests poor healing, which is often due to a combination of factors including immobility, malnutrition, and other risk factors. The Braden Scale score reflects several high-risk areas that contribute to the poor healing of the pressure injury.
Actions to Take

1. Apply pressure reduction mattress to bed
A pressure reduction mattress helps alleviate pressure on vulnerable areas and can significantly reduce the risk of further injury and promote healing. It is a crucial intervention for managing pressure injuries and preventing new ones.
2. Request service of wound care nurse
Consulting a wound care nurse can provide specialized assessment and treatment for the pressure injury. This professional can recommend advanced wound care techniques and products to support optimal healing and address any complications.
Parameters to Monitor

1. Progression of wound
Monitoring the progression of the wound involves assessing changes in size, depth, and appearance of the pressure injury. This helps evaluate the effectiveness of interventions and the rate of healing.
2. Adherence to repositioning schedule

Regular repositioning is crucial to relieve pressure on vulnerable areas and prevent further injury. Ensuring that the client is repositioned according to the schedule helps prevent pressure ulcers from worsening and supports healing.
Incorrect conditions

Immobility: Although immobility is a factor in pressure injuries, the direct intervention would be to improve mobility, not necessarily apply to the current situation.
Dehydration: While dehydration can affect skin health and healing, the primary condition here is the poor healing of the pressure injury rather than dehydration itself.
Malnutrition: Malnutrition can impair wound healing, but the immediate action would be more related to wound care and pressure relief. Nutrition might be addressed separately through dietary interventions.