A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?

Fatigue related to disease exacerbation.

Pain related to joint inflammation

Impaired physical mobility related to joint pain.

Self-care deficit related to disease progression.

Answer and Explanation

The Correct Answer is B

A.   This is a valid nursing problem and directly related to the client's condition. However, while fatigue is a significant concern, it is often a symptom of other underlying issues.

B.   This is the highest priority nursing problem. Pain is a primary symptom of acute RA exacerbation and significantly impacts the client's quality of life, mobility, and overall well-being. Addressing pain is crucial for immediate comfort and to facilitate other interventions.
C.   This is also a valid nursing problem, directly linked to the client's symptoms. However, it is a consequence of the pain, not the primary issue. Addressing the pain will improve mobility.
D.   This is a potential long-term concern but not the highest priority at this acute stage. The client's immediate needs related to pain and mobility are more pressing.

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Correct Answer is A

Explanation

A. Placing protective padding between the client and bed rails is a safety measure to prevent injury during a seizure. This action helps protect the client from head or body trauma if they hit the bed rails or any surrounding surfaces during the seizure.
B. Providing privacy is important for maintaining the client’s dignity during a seizure, but it is not the most immediate concern. The primary focus during a seizure should be on ensuring the client’s safety and monitoring the event. Privacy can be considered once the immediate safety and medical needs are addressed.
C. Observing the client's behavior during the seizure is essential for documentation and subsequent medical evaluation. It helps in identifying the type, duration, and characteristics of the seizure, which is crucial for diagnosis and treatment. However, observation alone does not address immediate safety needs or interventions required during the seizure.
D. Recording the client's level of consciousness after the seizure is important for assessing the postictal state and the extent of recovery. This information is valuable for understanding the impact of the seizure and guiding further medical care. However, during the seizure, immediate actions should focus on ensuring safety and managing the seizure itself.

A. Assess the client's oxygen saturation level. B. Determine the client's current glucose level C. Give the client one-half cup of fruit juice. D. Give the client skim milk and crackers.

Correct Answer is B

Explanation

A. While oxygen saturation is important, it's not the priority in this situation. The client's symptoms strongly suggest hypoglycemia.
B. The client's symptoms of diaphoresis, rapid heartbeat, and shakiness are classic signs of hypoglycemia. Therefore, the first action should be to confirm this diagnosis by checking the blood glucose level.
C. Administering glucose before confirming hypoglycemia can be dangerous. If the client is hyperglycemic, giving them sugar will worsen their condition.
D. Providing food without confirming hypoglycemia is not appropriate.

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A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet, swelling, redness, restricted joint motion, and reports feeling fatigued. Which nursing problem has the highest priority for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse observes a client who begins to exhibit continuous jerking movements, is unable to speak, and is incontinent of urine during the event. Which action is most important for the nurse to take?

Correct Answer is A

Explanation

A client with type 2 diabetes mellitus (DM) is admitted to the hospital for uncontrolled DM. Insulin therapy is initiated with an initial dose Isophane suspension insulin at 0800. At 1600, the client reports having diaphoresis, rapid heartbeat, and feeling shaky. Which should the nurse do first?

Correct Answer is B

Explanation

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