A nurse is caring for a patient with rheumatoid arthritis who is struggling to perform activities of daily living (ADLs) due to joint pain and stiffness. Which nursing intervention should the nurse prioritize to best assist the patient?
Provide the patient with assistive devices for personal care.
Teach the patient range of motion exercises to improve flexibility
Encourage the patient to take over-the-counter medications for pain relief.
Instruct the patient to rest and avoid all physical activity
The Correct Answer is A
Rationale:
A. Rheumatoid arthritis (RA) can limit a patient’s ability to perform ADLs due to joint pain, stiffness, and reduced grip strength. Providing assistive devices such as adaptive utensils, dressing aids, or jar openers allows the patient to maintain independence, safety, and functional ability, which is the nurse’s priority.
B. While range of motion exercises are important for long-term joint mobility and preventing contractures, they are not the immediate intervention to help the patient perform ADLs safely and independently. Exercise can be introduced once basic functional needs are supported.
C. Pain management may be part of care, but over-the-counter medications may be insufficient or unsafe depending on the patient’s condition and medications. This does not directly address the functional limitation in performing ADLs.
D. Complete rest can lead to muscle atrophy, joint stiffness, and decreased independence, which may worsen functional impairment. RA management balances rest and gentle activity, but avoiding all movement is not recommended.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C","D","F"]
Explanation
Rationale:
A. Clients in myxedema coma are often hypothermic, lethargic, or obtunded and may be unable to safely swallow. Oral intake is not reliable and can increase the risk of aspiration, so nutrition and fluids are administered intravenously until the patient is stabilized.
B. Myxedema coma can lead to respiratory depression, hypoventilation, and CO₂ retention. Supporting the airway and providing mechanical ventilation when needed is a priority intervention to maintain oxygenation and prevent respiratory failure.
C. Patients often present with hypotension, hyponatremia, and dehydration. IV fluids help restore intravascular volume, maintain perfusion, and correct electrolyte imbalances, which are essential for stabilizing cardiovascular function.
D. Myxedema coma can cause bradycardia, low cardiac output, and ECG changes. Continuous cardiac monitoring is critical because arrhythmias can develop rapidly and may be life-threatening.
E. Myxedema coma is associated with severe hypothermia, not hyperthermia. Active cooling would worsen the patient’s condition. Instead, passive rewarming with blankets and a warm environment is appropriate.
F. Thyroid hormone replacement is essential and life-saving in myxedema coma. IV administration is necessary because oral absorption may be unreliable due to decreased gastrointestinal motility or altered consciousness.
Correct Answer is ["C","E"]
Explanation
Rationale:
A. AB- blood contains both A and B antigens on the red blood cells. A recipient with blood type A- has anti-B antibodies in their plasma. If AB- blood is transfused, the recipient’s immune system will recognize the B antigens as foreign, leading to a potentially dangerous hemolytic reaction.
B. While A+ blood has the A antigen that matches the recipient’s ABO type, it is Rh-positive, and the recipient is Rh-negative (A-). Transfusing Rh-positive blood to an Rh-negative individual can trigger alloimmunization, where the immune system develops antibodies against the Rh factor. This is especially concerning in women of childbearing age, as it may affect future pregnancies, and it can also cause hemolytic transfusion reactions.
C. O- blood has no A or B antigens and is Rh-negative, making it the universal donor for red blood cells. An A- recipient will not react immunologically to O- red blood cells because there are no antigens to trigger an antibody response. O- blood is safe for emergency transfusions when a perfectly matched unit is unavailable.
D. AB+ blood contains A and B antigens as well as Rh-positive antigen. Transfusing AB+ to an A- recipient is incompatible because the B antigens would trigger anti-B antibodies and the Rh-positive factor could cause alloimmunization, making this combination unsafe.
E. A- blood is both ABO compatible (A antigen matches) and Rh compatible (negative). This is the ideal match for an A- recipient because it eliminates the risk of immune-mediated hemolysis and ensures safe transfusion.
F. Although O blood lacks A and B antigens, O+ blood contains the Rh D antigen, which is incompatible with an Rh-negative recipient. Transfusing O+ blood to an A- recipient could trigger alloimmunization or hemolytic reaction, so it is unsafe.
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