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Exhibits

Data is evaluated to determine possible condition and appropriate interventions.

Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

Answer and Explanation

The Correct Answer is []

Potential Condition:

Rheumatoid arthritis (RA):
- RA is a chronic autoimmune disorder that causes inflammation in the joints, leading to pain, stiffness, and swelling.
- The patient has several classic signs of RA:
  - Pain and stiffness in bilateral hands and wrists: A hallmark of RA, particularly in the morning (worse upon waking).
  - Positive rheumatoid factor and positive antinuclear antibody: Both are commonly seen in RA.
  - Elevated erythrocyte sedimentation rate (ESR): This indicates inflammation, which is typical in RA.
  - X-ray findings of soft tissue swelling and marginal erosions: These are common in RA and suggest joint damage.

Actions to Take:

Educate on disease process and management:
- It’s essential for the nurse to educate the patient on RA, its chronic nature, and the need for lifelong management. This will include medication adherence, managing flare-ups, and joint protection techniques.
Consult dietician for nutrition and weight loss:
- Obesity can exacerbate RA symptoms due to increased joint stress. Encouraging weight loss can help reduce strain on affected joints and improve overall health. A dietician can help with weight management strategies and recommend anti-inflammatory foods.

Parameters to Monitor:

Pain:
- Monitoring pain levels regularly is critical for assessing the effectiveness of treatment and making necessary adjustments to the pain management plan (e.g., the ibuprofen regimen).
Blood glucose:
- Since the patient has a BMI of 31, there is an increased risk for type 2 diabetes mellitus, which is common in patients with RA. Additionally, if the patient is prescribed corticosteroids for RA management, monitoring blood glucose is crucial, as corticosteroids can elevate blood sugar levels

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Correct Answer is []

Explanation

Potential Condition

- Dilated Cardiomyopathy: This condition is most likely because the client presents with symptoms of heart failure (chest pain, dizziness, inspiratory crackles, systolic murmur, and ankle edema) alongside a history of hypertension, which can contribute to the development of dilated cardiomyopathy.

Actions to Take

1. Apply Oxygen: The client is showing signs of potential heart failure, and oxygen can help alleviate symptoms associated with decreased oxygenation.

2. Perform 12-lead EKG: An EKG will provide information about any potential cardiac abnormalities, especially in the presence of chest pain and systolic murmur.

Parameters to Monitor

1. Blood Pressure: It is essential to monitor blood pressure due to the client's hypertension and heart failure symptoms, which may be exacerbated by elevated blood pressure.

2. Urine Output: Monitoring urine output helps assess kidney perfusion and fluid status, which can be affected by heart failure and hypertension, particularly in cases of cardiomyopathy.

A. Monitor blood glucose levels daily. B. Monthly appointments with the dietitian. C. Regular exercise with medical approval. D. Limit calories on days unable to exercise.

Correct Answer is C

Explanation

A. While monitoring blood glucose levels is important for managing diabetes, this instruction alone does not specifically address the goal of lowering blood glucose levels and increasing HDL levels.

B. Monthly appointments with a dietitian can be beneficial but are not as essential as incorporating regular exercise into the client’s lifestyle.

C. Regular exercise is a key component in managing type 2 diabetes, as it helps to lower blood glucose levels and can improve HDL cholesterol. Medical approval ensures that the exercise regimen is safe for the client.

D. Limiting calories on days unable to exercise is not a primary focus for managing diabetes and may not be practical or effective in promoting overall health.

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Naxlex Comprehensive Predictor Exams

Correct Answer is []

Explanation

The nurse is developing a plan of care for a client with type 2 diabetes mellitus (DM). When providing teaching on lowering blood glucose levels and increasing serum high-density lipoprotein (HDL) levels, which instruction should the nurse include?

Correct Answer is C

Explanation

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