A nurse is caring for a client whose partner has a terminal diagnosis. Which of the following statements made by the client indicates effective coping?

A. A client who has aspiration pneumonia: Pneumonia leads to hypoventilation and carbon dioxide retention, which causes respiratory acidosis. It does not typically result in metabolic alkalosis since it affects gas exchange rather than acid-base balance at the metabolic level.

B. A client who is receiving continuous gastric suctioning: Prolonged removal of gastric secretions depletes hydrochloric acid, leading to an excess of bicarbonate in the blood and resulting in metabolic alkalosis. This is a common cause of alkalosis, along with excessive vomiting or diuretic use.

C. A client who is experiencing an opioid overdose: Opioids depress the respiratory system, reducing ventilation and causing carbon dioxide buildup, leading to respiratory acidosis. This does not cause metabolic alkalosis, as the issue originates in the lungs, not metabolism.

D. A client who has uncontrolled diabetes mellitus: Diabetic ketoacidosis results in excessive production of acidic ketone bodies, which lower blood pH and cause metabolic acidosis. The acid-base disturbance in diabetes is typically acidosis, not alkalosis.

Condition:

• Rheumatoid arthritis

Actions to Take:

• Assess joints for warmth and redness.
• Assess for paresthesias.

Parameters to Monitor:

• Weight-bearing joints.
• Decreased immunity.

Rationale:

Condition Choices

• Osteoporosis: Osteoporosis primarily leads to bone demineralization and increased fracture risk rather than inflammatory joint pain, swelling, and systemic symptoms such as fever and fatigue. The client’s symptoms, including joint inflammation and subcutaneous nodules, are not characteristic of osteoporosis.
• Osteoarthritis: Osteoarthritis typically presents with asymmetric joint involvement, stiffness that worsens with activity, and crepitus in weight-bearing joints. The client’s symptoms, including symmetric joint swelling, prolonged morning stiffness, and systemic inflammation markers, are more consistent with an autoimmune disorder like rheumatoid arthritis.
• Rheumatoid arthritis: The presence of bilateral joint pain, stiffness, swelling, subcutaneous nodules, and elevated inflammatory markers (ESR and CRP) strongly suggests rheumatoid arthritis. The morning stiffness, systemic symptoms like fatigue and low-grade fever, and the impact on mobility further support this diagnosis.
• Gout: Gout is characterized by acute, episodic joint pain, typically affecting the metatarsophalangeal joint of the big toe. The client’s symptoms are more widespread and chronic, involving multiple joints and systemic inflammation, which is not typical of gout.

Actions to Take

• Assess joints for warmth and redness: Inflammation in rheumatoid arthritis leads to synovial swelling, warmth, and redness. Regular assessment helps track disease progression and the effectiveness of treatment.
• Assess for paresthesias: Chronic inflammation and joint deformities in rheumatoid arthritis can lead to nerve compression, resulting in numbness or tingling, particularly in the hands and feet.
• Assess for crepitus in weight-bearing joints: Crepitus is more commonly associated with osteoarthritis due to cartilage degeneration. While rheumatoid arthritis affects weight-bearing joints, it does so through inflammatory destruction rather than mechanical wear.
• Recommend the client spend at least 5 min outside in the sun daily: Sun exposure can help with vitamin D synthesis, but rheumatoid arthritis is not primarily related to vitamin D deficiency. This intervention is more relevant for osteoporosis management.

Parameters to Monitor

• Weight-bearing joints: Rheumatoid arthritis commonly affects the knees, hips, and other weight-bearing joints, contributing to mobility issues and falls. Monitoring joint involvement helps assess disease progression.
• Decreased immunity: Rheumatoid arthritis and its treatments, such as immunosuppressive medications, increase the risk of infections. Monitoring for signs of immunosuppression is essential for early intervention.
• Joint inflammation in the big toe: This is more indicative of gout, which presents with acute episodes of pain and swelling in the first metatarsophalangeal joint rather than the widespread, chronic inflammation seen in rheumatoid arthritis.
• Calcium and vitamin D levels: While important for bone health, these levels do not provide direct insight into rheumatoid arthritis progression. They are more relevant in osteoporosis management.
• Cervical neck pain: While rheumatoid arthritis can affect the cervical spine, particularly at the atlantoaxial joint, the primary concern is peripheral joint inflammation and systemic symptoms rather than isolated neck pain.