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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:

  1. 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.
  2. 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:

  1. 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).
  2. 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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Related Questions

Correct Answer is B

Explanation

A. Internal bleeding typically presents with signs of hypovolemia, such as decreased blood pressure and increased heart rate, rather than pitting edema and jugular venous distention.

B. Right-sided heart failure is characterized by fluid overload, leading to symptoms like pitting edema in the extremities and jugular venous distention, which align with the findings observed in this client.

C. Left ventricular dysfunction primarily results in pulmonary congestion and respiratory distress rather than peripheral edema and jugular venous distention.

D. Cardiac tamponade may present with jugular venous distention, but it usually also involves hypotension and muffled heart sounds, which are not described in this scenario.

Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}

Explanation

Based on history and assessment data, the nurse should prioritize activity intolerance as the priority problem for this client, as evidenced by the client's statement "I just can't catch my breath."

Rationale:

  • Activity intolerance: The client's shortness of breath and wheezing indicate impaired gas exchange and reduced oxygenation, which limits their ability to engage in physical activity.
  • Anxiety: While anxiety can exacerbate asthma symptoms, the immediate priority is to address the physiological issue of impaired gas exchange.

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