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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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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is ["A","D","E"]

Explanation

A. Administer medications as prescribed. This includes the albuterol/ipratropium nebulizer treatment and oral prednisone, which are essential for managing acute asthma exacerbations.

B. Ask the client for a list of current medications: While this information is important, it is not the immediate priority in managing an acute asthma exacerbation.

C. Notify the healthcare provider of the client's need for intubation: Intubation is a more invasive procedure and is typically reserved for severe cases of respiratory distress that are not responding to medical therapy. In this case, the client's condition is not severe enough to warrant immediate intubation.

D. Apply oxygen via nasal cannula. The client's oxygen saturation is below 94%, indicating hypoxemia, and supplemental oxygen is necessary to improve oxygenation.

E. Provide client teaching. This includes educating the client about asthma triggers, medication adherence, and early signs of an asthma exacerbation.

F. Place the client in Trendelenburg position: This position is not indicated for asthma exacerbations. It is typically used for conditions like shock or hypotension.

A. rescue inhaler three times B. symptoms seem worse when outdoors and when exercising C. episodes like this make him extremely nervous

Correct Answer is ["A","B"]

Explanation

Rescue inhaler three times: The fact that the client used his rescue inhaler three times without relief indicates that his asthma symptoms are not adequately controlled, and he may need further medical intervention or adjustments in his asthma management plan.

Symptoms seem worse when outdoors and when exercising: This suggests that environmental triggers and physical activity exacerbate his asthma, indicating a need for tailored management strategies, possibly including preventive measures or medications before exposure to these triggers

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Exhibits The nurse has identified the priority problem for the client and now must determine proper care interventions. Based on the client history and the assessment data, which action(s) should the nurse anticipate? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

Correct Answer is ["A","B"]

Explanation

A client with stage IV bone cancer is admitted to the hospital for pain control. The client verbalizes continuous, severe pain of 8 on a 0 to 10 scale. Which intervention should the nurse implement?

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While caring for a client with a full thickness burn covering 40% of the body, the nurse observes purulent drainage at the wound. Before reporting this finding to the healthcare provider, the nurse should review which of the client's laboratory values?

During a home visit, the nurse assesses the skin of a client with eczema who reports that an exacerbation of symptoms has occurred during the last week. Which information is most useful in determining the possible cause of the symptoms?

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