A nurse is providing discharge teaching to a client who has a gastric ulcer and a new prescription for esomeprazole.
Which of the following information should the nurse include in the teaching?

Choice A rationale: Persistent coughing with mucopurulent sputum suggests an ongoing respiratory infection or inflammation. Mucopurulent sputum indicates the presence of neutrophils and bacteria, often seen in bacterial pneumonia or tuberculosis. While significant, coughing alone is not an immediate life-threatening finding but rather a symptom requiring monitoring and further diagnostic follow-up to confirm the cause.

Choice B rationale: Joint pain in a patient receiving infliximab for rheumatoid arthritis may reflect an autoimmune flare or side effects of immunosuppression. Although uncomfortable and significant for quality of life, joint pain does not usually require immediate intervention compared to respiratory or infectious signs that may threaten life or transmission risk.

Choice C rationale: Anorexia, or decreased appetite, is a common systemic symptom in chronic infections like tuberculosis. It reflects the body’s inflammatory response and catabolic state but is a nonspecific finding. It requires addressing nutritional support but is not immediately life-threatening or requiring urgent intervention compared to active infectious disease signs.

Choice D rationale: Night sweats are a classic systemic symptom of tuberculosis caused by cytokine-mediated thermoregulatory dysfunction during infection. Although important in clinical suspicion, night sweats themselves do not necessitate immediate intervention but support the need for further diagnostic workup and infection control precautions.

Choice E rationale: An 11 mm induration on the purified protein derivative (PPD) test is considered positive in this patient due to immunosuppression with infliximab, which increases TB risk. The normal cutoff varies by risk factors, but 5 mm or greater is positive in immunosuppressed patients. This finding requires urgent follow-up to initiate treatment and prevent active disease and transmission, making it the most critical.

Choice A rationale

Administering diclofenac at bedtime does not specifically mitigate its gastrointestinal side effects. NSAIDs like diclofenac can cause gastric irritation and ulceration by inhibiting cyclooxygenase-1 (COX-1), which produces prostaglandins essential for gastric mucosal protection. Time of administration is less critical than co-administration with food or protective agents.

Choice B rationale

Antacids can interfere with the absorption of some medications, but specifically for diclofenac, avoiding concomitant administration is not a standard recommendation to mitigate adverse effects. In fact, antacids can sometimes be used to alleviate gastric distress associated with NSAIDs, although they do not prevent direct mucosal damage.

Choice C rationale

Diclofenac is a nonsteroidal anti-inflammatory drug (NSAID) that can irritate the gastric mucosa, potentially causing dyspepsia, nausea, and ulceration. Administering the medication with food or milk helps to buffer the gastric acid and physically protect the stomach lining, thereby reducing the direct irritant effect on the gastrointestinal tract and enhancing tolerability.

Choice D rationale

Diclofenac is typically formulated as an enteric-coated tablet or delayed-release capsule to protect the stomach from irritation and ensure targeted drug release in the small intestine. Crushing the medication would destroy this protective coating, leading to premature drug release in the stomach, increasing gastric irritation, and potentially reducing therapeutic efficacy.