A nurse in an outpatient clinic is caring for a client.

Exhibits

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Condition: Osteoarthritis

The client reports pain in the right knee and left wrist over the last two years. OA typically presents with chronic, localized joint pain, particularly in weight-bearing joints (e.g., knees) and joints that experience repetitive use (e.g., wrists).
Crepitus (a crackling or grating sound when the joint moves) is noted in both the right knee and left wrist, which is a characteristic finding in osteoarthritis due to cartilage breakdown and joint space narrowing.
The absence of systemic symptoms such as rashes or other joint pain, as well as normal laboratory values (e.g., normal ESR, normal ANA), further supports a diagnosis of osteoarthritis rather than conditions like systemic lupus erythematosus (SLE) or rheumatoid arthritis (RA), which are associated with systemic inflammation.

Actions to Take for Osteoarthritis:

Instruct the client to apply heat and cold:

Heat and cold therapy can help manage the pain and stiffness associated with osteoarthritis. Cold therapy can reduce inflammation, while heat therapy can improve blood flow and relax the muscles around the joint.

Instruct the client to apply topical analgesics:

Topical analgesics (such as menthol or capsaicin creams) can provide localized pain relief for osteoarthritis. They are commonly used as part of the non-pharmacological treatment approach for joint pain.

Parameters to Monitor for Osteoarthritis:

ESR (Erythrocyte Sedimentation Rate):

While osteoarthritis is generally not associated with systemic inflammation, monitoring the ESR can help ensure that there are no signs of additional inflammatory processes (such as rheumatoid arthritis) that might be missed. In this case, the client's ESR is within the normal range (20 mm/hr), which supports the diagnosis of osteoarthritis.

Joint deformities:

Monitoring for joint deformities over time is essential in osteoarthritis to assess disease progression. OA can lead to the formation of osteophytes (bone spurs) and other joint deformities that might impair function.

Explanation for incorrect choices; Systemic Lupus Erythematosus (SLE):

SLE typically presents with a variety of symptoms, including a characteristic butterfly-shaped rash on the face, photosensitivity, and systemic involvement such as kidney or neurological issues. The client does not exhibit any skin rashes, systemic symptoms, or abnormal ANA (antinuclear antibody), which would be elevated in SLE.

Gout:

Gout involves the deposition of uric acid crystals in joints, leading to sudden, severe pain, usually in the big toe (but other joints can be involved). While the client has a mildly elevated uric acid level (7.2 mg/dL, which is within the upper limit), there are no signs of an acute gout flare (such as intense joint pain, redness, and swelling). Additionally, the client’s symptoms are chronic, which is more consistent with OA.

Rheumatoid Arthritis (RA):

RA is an autoimmune disease that causes inflammation and deformities in the joints, usually in a symmetrical pattern (e.g., both wrists or knees). The client’s presentation does not fit this pattern, and laboratory results (normal ANA, ESR) do not suggest an autoimmune inflammatory condition like RA.

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Free Nursing Study Resources

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

Explanation

Rationale
1. History and Physical
Last pregnancy resulted in a preterm spontaneous vaginal birth at 30 weeks
The client's history of a preterm birth at 30 weeks in a previous pregnancy is a significant risk factor for preterm labor in the current pregnancy. A history of preterm labor increases the likelihood of recurrence, and close monitoring is essential. This information alone does not require immediate follow- up but is important in guiding the overall care plan and risk assessment for preterm labor.
2. Nurses' Notes
Lower back pain and pinkish vaginal discharge.
Lower back pain and pinkish vaginal discharge are common symptoms of preterm labor. The pinkish vaginal discharge could indicate bloody show, which is sometimes seen with cervical dilation or preterm labor.
Uterine contractions every 8 minutes, palpate strong, duration 30 seconds.
Regular uterine contractions (every 8 minutes) in a client at 33 weeks gestation could indicate preterm labor. Contractions every 8 minutes with strong palpation and 30-second duration should be further assessed for their frequency, intensity, and impact on cervical dilation. This finding requires follow-up to determine whether these contractions are progressing to actual labor.
Minimal variability.
Minimal variability can sometimes be a sign of fetal distress or hypoxia, but it can also be seen in some normal circumstances. However, it is a finding that requires closer observation and may warrant further investigation to assess fetal well-being, especially in the context of preterm labor.
Finding: Cervical exam indicates 2 cm, 50% effaced, 0 station.
The cervix is 2 cm dilated, 50% effaced, and at a station of 0. This indicates that the cervix is beginning to open and efface, which is a sign of early labor. Since the client is at 33 weeks gestation, this is concerning for preterm labor, and the client should be closely monitored for further cervical changes and labor progression.

A. Perform suctioning B. Withhold pain medication for headache until other manifestations resolve. C. Assess blood pressure every 15 min. D. Administer nifedipine. E. Assess for urinary retention. F. Place client in supine position.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

1. Perform suctioning

Contraindicated

Suctioning can be a stressor to the body, and in patients with autonomic dysreflexia, it could potentially exacerbate the condition and lead to further increases in blood pressure. In autonomic dysreflexia, managing the underlying trigger (such as a full bladder or bowel impaction) is key, not suctioning unless there is a specific need related to respiratory issues. This action could make the elevated blood pressure worse.
2. Withhold pain medication for headache until other manifestations resolve

Contraindicated
Pain management is critical in a patient with autonomic dysreflexia. The headache is a significant symptom of autonomic dysreflexia and needs to be addressed immediately, as pain is often the trigger. Withholding pain medication could worsen the client's symptoms and contribute to further complications. Proper management of pain should occur concurrently with interventions to address the elevated blood pressure.
3. Assess blood pressure every 15 minutes

Anticipated
Monitoring blood pressure is crucial in patients with autonomic dysreflexia to track changes and assess for improvement or worsening of hypertension. The nurse should frequently assess the client’s blood pressure to ensure it is returning to normal after appropriate interventions are initiated. Autonomic dysreflexia requires continuous monitoring of blood pressure to avoid complications such as stroke or cardiac events.
4. Administer nifedipine

Contraindicated
While nifedipine (a calcium channel blocker) is used to manage hypertension, it is not typically recommended as a first-line treatment for autonomic dysreflexia in spinal cord injury patients. Instead, interventions should focus on removing the triggering stimulus (e.g., bladder distension, constipation, or pressure ulcers). If blood pressure does not respond, other medications such as nitroglycerin or hydralazine may be used, but nifedipine is not the preferred option.
5. Assess for urinary retention

Anticipated
Urinary retention is a common trigger for autonomic dysreflexia in patients with spinal cord injuries, particularly those with injuries at or above T6. If the client is experiencing symptoms of autonomic dysreflexia, one of the first steps is to assess for urinary retention. If the bladder is full, catheterization may be required to relieve the pressure and help normalize the blood pressure. The nurse should assess the client’s urinary status promptly.
6. Place client in supine position

Contraindicated
In the case of autonomic dysreflexia, placing the client in a supine position could potentially worsen the elevated blood pressure by increasing venous return and making it harder for the body to normalize blood pressure. The client should be positioned sitting upright or at a 45-degree angle, which can help lower blood pressure by promoting venous pooling and reducing the effects of the autonomic dysreflexia response.

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Naxlex Comprehensive Predictor Exams

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

Explanation

A nurse is caring for a client who has a spinal cord injury. Exhibits For each potential nursing action, click to specify if the action is anticipated or contraindicated for the client.

Correct Answer is {"A":{"answers":"B"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"B"}}

Explanation

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