A client with rheumatoid arthritis has an elevated serum rheumatoid factor. Which interpretation of this finding should the nurse make?

Choice A reason: Cleaning the tongue and mouth with swabs is not the best initial nursing action, as it can cause more irritation and pain to the mucous membranes. Swabs can be abrasive and harsh on the inflamed and ulcerated tissues. The client should use a soft toothbrush or a sponge to gently clean the tongue and mouth, and avoid alcohol-based mouthwashes or rinses.

Choice B reason: Administering a topical analgesic per protocol is the best initial nursing action, as it can provide immediate relief and comfort to the client. Topical analgesics can numb the nerve endings and reduce the sensation of pain in the tongue and mouth. The client should follow the health care provider's instructions on how to apply the analgesic, and avoid eating or drinking for at least 30 minutes after the application.

Choice C reason: Obtaining a soft diet for the client is a correct nursing action, but not the best initial one, as it can help prevent further trauma and damage to the mucous membranes. A soft diet consists of foods that are easy to chew and swallow, such as soups, puddings, yogurts, and mashed potatoes. The client should avoid foods that are spicy, acidic, salty, or hard, such as citrus fruits, tomatoes, chips, and nuts.

Choice D reason: Encouraging frequent mouth care is a correct nursing action, but not the best initial one, as it can help prevent infection and promote healing of the mucous membranes. Frequent mouth care involves rinsing the mouth with water or saline solution several times a day, especially after meals and before bedtime. The client should also keep the lips moist with a lip balm or petroleum jelly.

Choice A reason: Reorienting to day and time frequently is a nursing intervention that the nurse should implement, because it can help the client to reduce confusion, anxiety, and disorientation, which may contribute to the auditory hallucinations. The nurse should use simple and clear language, speak slowly and calmly, and provide cues and reminders, such as a clock, a calendar, or a picture, to help the client to orient to reality.

Choice B reason: Applying soft wrist restraints bilaterally is not a nursing intervention that the nurse should implement, unless it is absolutely necessary and ordered by the doctor. Restraints can increase the client's agitation, anxiety, and fear, and they can also cause physical and psychological harm, such as skin breakdown, nerve damage, or loss of dignity. The nurse should use restraints only as a last resort, after trying other less restrictive alternatives, such as verbal de-escalation, distraction, or medication.

Choice C reason: Administering a PRN dose of lorazepam is a nursing intervention that the nurse should implement, if it is prescribed by the doctor and indicated by the client's condition. Lorazepam is a benzodiazepine that can help the client to relax, reduce anxiety, and sedate the central nervous system, which may alleviate the auditory hallucinations. The nurse should monitor the client's vital signs, level of consciousness, and respiratory status, and report any adverse effects, such as hypotension, bradycardia, or respiratory depression.

Choice D reason: Turning the television on for distraction is not a nursing intervention that the nurse should implement, because it can worsen the client's auditory hallucinations, confusion, and agitation. The television can provide too much stimulation, noise, and information, which can overload the client's sensory perception and interfere with their ability to distinguish reality from hallucination. The nurse should provide a quiet and calm environment, and limit the sources of auditory input.

Choice E reason: Presenting a calm, supportive demeanor is a nursing intervention that the nurse should implement, because it can help the client to feel safe, comfortable, and respected, and to establish a trusting relationship with the nurse. The nurse should show empathy, compassion, and patience, and avoid arguing, criticizing, or dismissing the client's hallucinations. The nurse should acknowledge the client's feelings, validate their distress, and reassure them that they are not alone.