The nurse assesses a client with rheumatoid arthritis (RA) and Sjögren syndrome. What assessment would be most important for this client?

Abdominal assessment.

Oxygen saturation.

Breath sounds.

Visual acuity.

Answer and Explanation

The Correct Answer is D

Choice A reason: Abdominal assessment is less critical in RA and Sjögren syndrome, as these conditions primarily affect joints and exocrine glands, respectively. Gastrointestinal issues may occur with RA medications (e.g., NSAIDs), but they are not the primary concern compared to ocular complications.
Choice B reason: Oxygen saturation is not directly impacted by RA or Sjögren syndrome unless secondary complications like interstitial lung disease (rare in RA) are present. It is less relevant than ocular assessments for Sjögren syndrome’s hallmark dry eye complications.
Choice C reason: Breath sounds may be assessed in RA for rare pulmonary complications, but Sjögren syndrome primarily causes sicca symptoms (dry eyes and mouth). Respiratory issues are not the primary concern, making this less critical than ocular assessment.
Choice D reason: Sjögren syndrome causes reduced tear production, leading to dry eyes, which can result in corneal damage, infections, or vision loss. Assessing visual acuity is critical to detect early ocular complications, making it the most important assessment for this client’s condition.

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Correct Answer is C

Explanation

Choice A reason: Green-blue discharge suggests infection, possibly bacterial (e.g., Pseudomonas), but is not specific to tympanic membrane rupture. In otitis media with effusion, discharge may occur with perforation, but the color is not diagnostic of rupture itself.
Choice B reason: Increased temperature is common in otitis media due to infection but does not specifically indicate tympanic membrane rupture. Fever reflects systemic inflammation, not the mechanical event of perforation, which is better indicated by other symptoms.
Choice C reason: Sudden pain relief in otitis media with effusion occurs when a tympanic membrane rupture releases pressure from fluid buildup in the middle ear. This alleviates the intense pain caused by pressure on the membrane, making it a hallmark sign of perforation.
Choice D reason: A popping sensation when swallowing may occur due to eustachian tube dysfunction but is not specific to tympanic membrane rupture. It reflects pressure changes in the middle ear, not the acute event of perforation.

A. Place the client in a high-Fowler position. B. Document the client’s oxygen saturation level. C. Start oxygen therapy at 2 L/min via nasal cannula. D. Contact the primary health care provider.

Correct Answer is B

Explanation

Choice A reason: Placing the client in a high-Fowler position may improve breathing but does not assess the cause of shortness of breath. Post-femur repair, pulmonary embolism (PE) is a risk due to fat emboli or thromboembolism, requiring objective data like oxygen saturation first.
Choice B reason: New-onset shortness of breath and tachypnea post-femur repair suggest possible pulmonary embolism or fat embolism syndrome. Documenting oxygen saturation provides objective data to assess hypoxia severity, guiding urgent interventions and communication with the healthcare provider for suspected life-threatening conditions.
Choice C reason: Starting oxygen therapy assumes hypoxia without confirmation. While it may be needed, assessing oxygen saturation first ensures the intervention is appropriate. Unwarranted oxygen administration could delay critical diagnostic steps for conditions like pulmonary embolism, which require anticoagulation or other therapies.
Choice D reason: Contacting the provider is important but secondary to assessing oxygen saturation, which provides critical data to report. Without objective findings, the nurse cannot convey the urgency or specifics of the client’s condition, potentially delaying life-saving interventions for suspected embolism.

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The nurse assesses a client with rheumatoid arthritis (RA) and Sjögren syndrome. What assessment would be most important for this client?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture?

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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