A nurse is planning care for a client who has rheumatoid arthritis and has moderate to severe pain in multiple joints. Which of the following actions should the nurse plan to take?
Perform ADLs for the client to promote rest.
Allow for frequent rest periods throughout the day.
Use heat to reduce joint inflammation.
Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain.
The Correct Answer is B
A. Perform ADLs for the client to promote rest. This is incorrect because performing ADLs for the client can increase their dependence and decrease their self-esteem. The nurse should encourage the client to perform ADLs as much as possible, with assistance as needed, to maintain their function and mobility.
B. Allow for frequent rest periods throughout the day. This is correct because rest periods can help reduce fatigue and pain, as well as prevent joint damage and inflammation. The nurse should balance rest and activity for the client and avoid overexertion.
C. Use heat to reduce joint inflammation. This is incorrect because heat can increase inflammation and pain in acute rheumatoid arthritis. The nurse should use cold applications to reduce swelling and inflammation in acute episodes, and use heat for chronic stiffness and pain.
D. Develop a daily schedule for acetaminophen up to 6 g/day that covers peak periods of pain. This is incorrect because acetaminophen has a maximum daily dose of 4 g/day, and exceeding this dose can cause liver toxicity. The nurse should monitor the client's liver function and use other analgesics as prescribed.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
Discourage physical activity during the day is incorrect. Encouraging physical activity is generally beneficial for individuals with dementia. Regular exercise can improve mood, reduce agitation, and enhance overall health. However, the level and type of physical activity should be tailored to the individual's abilities and preferences.
Choice B reason
Use clothing with buttons and zippers is incorrect. Clothing with buttons and zippers can be challenging for individuals with dementia due to fine motor skill impairments and difficulty with dressing. It is often recommended to use clothing with simple closures, such as Velcro or elastic bands, to make dressing easier and more manageable for the individual.
Choice C reason:
Individuals with dementia may experience difficulties with communication, memory, and problem-solving, which can affect their ability to recognize and express the need to use the restroom. As a result, they may be at risk of urinary or bowel incontinence. To address this concern and promote the client's comfort and dignity, establishing a toileting schedule is essential. A consistent routine for bathroom breaks can help prevent accidents and improve the client's overall well-being.
Choice D reason:
Engage the client in activities that increase sensory stimulation is incorrect. While sensory stimulation activities can be enjoyable and engaging for individuals with dementia, it is essential to select activities that are appropriate and not overwhelming. Some individuals with dementia may become overstimulated, which can lead to agitation or distress. Activities should be tailored to the individual's preferences and abilities.
Correct Answer is B
Explanation
A. Incorrect. Performing gastrostomy feedings is a complex task that requires specialized training and assessment skills. The nurse should not delegate this task to an AP who has not received the appropriate education and competency validation.
B. Correct. Determining if the PRN pain medication has helped is a simple task that involves asking the client about their pain level and documenting the response. The nurse can delegate this task to an AP as long as they follow up with the client and evaluate the effectiveness of the pain management plan.
C. Incorrect. Providing instructions about client care to a family member over the telephone is a task that requires clinical judgment and communication skills. The nurse should not delegate this task to an AP who might not have the knowledge or authority to answer questions or address concerns.
D. Incorrect. Teaching a client how to measure their own blood pressure is a task that requires teaching and evaluation skills. The nurse should not delegate this task to an AP who might not be able to explain the procedure, demonstrate the technique, or assess the client's learning.
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