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

Exhibits

Complete the following sentence by using the lists of options. The client is at highest risk for developing

evidenced by the client's
Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

  • Rheumatoid arthritis is the most likely condition given the client’s bilateral wrist and shoulder stiffness lasting for several hours in the morning, fatigue, and loss of appetite. The elevated ESR and anemia further support chronic inflammation. Positive ANA, while not specific, can be present in RA and other autoimmune disorders.
  • Osteoarthritis is incorrect because it typically presents with stiffness that improves within 30 minutes of activity, not lasting for several hours. It is also a non-inflammatory condition, whereas the client has elevated ESR and anemia, suggesting an inflammatory process.
  • Gout is unlikely as it usually causes acute, severe joint pain with redness and swelling, often affecting the big toe. The client’s uric acid level is within normal range, making gout less probable.
  • Carpal tunnel syndrome primarily causes numbness, tingling, and weakness in the hands due to median nerve compression. It does not typically cause prolonged morning stiffness, fatigue, or systemic inflammation.
  • Positive ANA is not the best choice because while it is seen in rheumatoid arthritis, it is also present in other autoimmune diseases such as lupus. It does not specifically confirm RA.
  • Normal WBC count does not support an inflammatory condition, as RA can lead to mild leukopenia, which is seen in the follow-up labs.
  • Low blood pressure is not a defining feature of RA and does not correlate with the client’s symptoms or disease progression


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Related Questions

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

Explanation

Rationale for Correct Options:

  • Urge to defecate occurs as the fetal head descends further into the birth canal, putting pressure on the rectum and perineum. This is a common sign of the second stage of labor, indicating that the client is nearing delivery.
  • Increased bloody show results from cervical dilation and effacement as the capillaries in the cervix rupture. A greater amount of blood-tinged mucus is expected as labor progresses, particularly in the transition phase and early second stage.
  • Cervix 10 cm dilated confirms that the client has reached full cervical dilation, which is required for the second stage of labor to begin. Complete dilation allows for the passage of the fetus through the birth canal.
  • Contractions strong on palpation indicate effective uterine activity, which is necessary for fetal descent and expulsion. Strong contractions help in moving the baby downward and increasing pressure on the cervix.

Rationale for Incorrect Options:

  • A heart rate of 110/min is elevated compared to the client’s earlier readings (90/min at 0830, 110/min at 0845) and may indicate maternal stress or exertion from labor pain. While mild increases in maternal heart rate are expected during labor, tachycardia above 110/min warrants further evaluation, particularly in the presence of fever.
  • Temperature of 39.1°C (102.4°F). This temperature is abnormally high and suggests infection, such as chorioamnionitis, especially considering the prolonged rupture of membranes since 1900 the previous night. Normal maternal temperature may rise slightly during labor due to exertion, but fever above 38°C (100.4°F) is concerning and requires medical attention.

Correct Answer is D

Explanation

A. "I will wipe away yellow crusts that form around the incision." Yellow crusting at the incision site is a normal part of the healing process. It should not be wiped away, as doing so could disrupt healing and cause irritation or bleeding. Instead, the area should be kept clean and allowed to heal naturally.
B. "I will apply antibiotic ointment to my baby's penis." The Plastibell technique does not require the application of antibiotic ointment. Unlike other circumcision methods, the Plastibell ring remains in place and falls off on its own within 5 to 8 days, reducing the need for additional topical treatments.
C. "I will make sure that my baby's diaper is applied snugly." The diaper should be applied loosely to prevent excessive pressure or friction on the healing area. A snug diaper can cause discomfort and increase irritation, potentially delaying healing.
D. "I will apply pressure with gauze if I see bleeding." Minor bleeding may occur after circumcision, and applying gentle pressure with sterile gauze is the appropriate action to control it. If bleeding persists beyond a few minutes or is excessive, medical attention should be sought immediately.

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