A nurse is caring for a client who is being treated for acute opioid toxicity. The client has a do-not-resuscitate (DNR) prescription, but the family would like to remove it. Which of the following responses should the nurse make?

Rationale:

A. "My provider will make my health care decisions if I complete advance directives.": Advance directives are designed to communicate the client’s own wishes regarding medical care, not to give the provider decision-making authority. The client retains the right to guide their care through these legal documents.

B. "A living will is a document that includes my wishes about health care decisions.": This statement demonstrates understanding because a living will specifies the client’s preferences for medical treatments, such as resuscitation or life-sustaining measures, in the event they are unable to communicate their wishes.

C. "My partner needs to be present as a witness when I sign a living will.": Witness requirements vary by state, but typically a living will requires impartial adult witnesses, not necessarily a partner, to prevent conflicts of interest. Believing the partner must be present reflects a misunderstanding of legal requirements.

D. "Advance directives outline who inherits my material possessions in the event of my death.": This describes a will, not an advance directive. Advance directives pertain to medical care decisions, not the distribution of property or assets.

Rationale for correct choices

• Osteoarthritis: The client presents with chronic, localized joint pain in the right knee and left wrist, along with crepitus and no systemic symptoms. Laboratory results show normal ESR and negative ANA, making inflammatory or autoimmune conditions unlikely. Osteoarthritis is a degenerative joint disease characterized by gradual cartilage breakdown, joint stiffness, and crepitus, consistent with this client’s findings.

• Instruct the client to apply heat and cold: Alternating heat and cold therapy helps reduce joint stiffness, improve circulation, and relieve pain in osteoarthritis. Heat can relax muscles and increase flexibility before activity, while cold can reduce inflammation and swelling after activity. Teaching the client proper application can improve comfort and functional mobility.

• Instruct the client to apply topical analgesics: Topical analgesics, such as NSAID gels or menthol-based creams, can provide localized pain relief without systemic side effects. This approach is particularly useful for clients with osteoarthritis who have isolated joint pain. Incorporating topical treatments into daily self-care can enhance quality of life and support mobility.

• Joint deformities: Monitoring joint deformities over time helps assess the progression of osteoarthritis. Osteophyte formation, malalignment, or decreased joint space can indicate worsening disease. Regular assessment allows early intervention to preserve function and prevent disability.

• ESR: Although ESR is normal in early osteoarthritis, monitoring it can help distinguish between degenerative and inflammatory processes if new symptoms arise. Tracking ESR ensures any unexpected systemic inflammation is promptly investigated, supporting accurate diagnosis and management.

Rationale for incorrect choices

• Gout: Gout typically presents with sudden, severe pain, redness, and swelling in a single joint, often the first metatarsophalangeal joint. The client’s chronic, gradual joint pain with crepitus and normal uric acid levels is not consistent with an acute gout flare, making this diagnosis unlikely.

• Systemic lupus erythematosus (SLE): SLE usually presents with multi-system involvement, positive ANA, rashes, and systemic inflammation. The client has negative ANA, no rashes, and localized joint pain, which rules out SLE as the primary condition.

• Rheumatoid arthritis (RA): RA is an autoimmune disease characterized by symmetrical joint involvement, morning stiffness lasting over an hour, and elevated inflammatory markers such as ESR. The client’s isolated joint involvement, absence of morning stiffness, and normal labs make RA unlikely.

• Instruct the client to avoid foods high in purines: Dietary purine restriction is relevant for gout, not osteoarthritis. Since the client does not exhibit acute gout symptoms and uric acid is within normal range, this action is unnecessary.

• Instruct the client to use mild soaps for cleansing skin: Skin care with mild soaps is a teaching point for autoimmune or dermatologic conditions, not osteoarthritis. It does not address joint pain, stiffness, or mobility, making it irrelevant in this case.

• Instruct the client to avoid live vaccines: Avoiding live vaccines is a precaution for immunosuppressed clients, such as those on immunosuppressants for RA or SLE. The client has osteoarthritis and is not immunocompromised, so this action is not indicated.

• Uric acid level: While uric acid is relevant for gout monitoring, the client’s uric acid is within normal range and osteoarthritis does not cause hyperuricemia. Therefore, this parameter is not necessary for monitoring in this case.

• Lymphadenopathy: Lymphadenopathy is associated with systemic infections or autoimmune conditions. The client does not show systemic involvement, so lymph node monitoring is not relevant.

• ANA: ANA testing is primarily used to screen for autoimmune disorders such as SLE. The client already has a negative ANA and does not present systemic symptoms, so repeating ANA is unnecessary.