The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

Encourage fluid intake.

Measure urine output.

Splint the affected joint.

Increase intake of red meat.

Answer and Explanation

The Correct Answer is A

A. Encourage fluid intake:
Encouraging fluid intake is the most appropriate action for the client experiencing gout, as it helps to promote the excretion of uric acid through urine. Increased fluid intake can help prevent the formation of urate crystals in the joints and reduce the severity and frequency of gout attacks. It is a fundamental aspect of managing gout and preventing future episodes.

B. Measure urine output:
While monitoring urine output is important for overall assessment, it is not specifically indicated in the management of acute gout attacks. Gout is primarily managed by addressing hyperuricemia and reducing inflammation in the affected joints, which is best achieved through hydration and pharmacological interventions.

C. Splint the affected joint:
Splinting the affected joint may provide some relief by immobilizing it and reducing movement, but it does not address the underlying cause of gout or promote the excretion of uric acid. Splinting is more commonly used in the management of injuries or conditions that require joint stabilization.

D. Increase intake of red meat:
Increasing intake of red meat is contraindicated in clients with gout because red meat contains high levels of purines, which can exacerbate hyperuricemia and increase the risk of gout attacks. Dietary modifications for gout typically involve reducing the consumption of foods high in purines, such as red meat, organ meats, and certain seafood.

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Correct Answer is D

Explanation

A) Closed ended questions:
Closed-ended questions typically elicit short, specific responses and may not provide comprehensive information about the sputum's characteristics.

B) Leading questions:
Leading questions suggest a particular answer and may bias the client's response, preventing the nurse from obtaining an accurate description of the sputum.

C) Detailed questions about a symptom:
While detailed questions can be useful, they may be too specific initially and might not allow the client to freely describe their sputum in their own words.

D) Open ended questioning:
Open-ended questions encourage the client to provide more detailed and descriptive responses, allowing the nurse to gather comprehensive information about the sputum's color, consistency, amount, and other characteristics. This technique is best for obtaining a thorough and accurate description of symptoms.

A. Obese, serious threat to well-being. B. Appropriate weight for height, good general health. C. Extreme obesity, at risk for multiple co-morbidities. D. Undernutrition, at risk for malnutrition.

Correct Answer is A

Explanation

A) Obese, serious threat to well-being: A BMI of 32 kg/m² places the client in the category of obesity (BMI ≥ 30 kg/m²). Obesity is a significant health concern associated with increased risks for various conditions such as cardiovascular disease, diabetes, hypertension, and certain cancers. The client's BMI indicates that she is obese, which poses a serious threat to her overall well-being and health.

B) Appropriate weight for height, good general health: This is incorrect because a BMI of 32 kg/m² does not fall within the normal range of 18.5 to 24.9 kg/m². The client is not at an appropriate weight for her height and is not considered to be in good general health based on this BMI.

C) Extreme obesity, at risk for multiple co-morbidities: While a BMI of 32 kg/m² does indicate obesity, it does not reach the threshold for extreme obesity (BMI ≥ 40 kg/m²). Therefore, the client is not categorized as extremely obese, although she is still at risk for several co-morbidities associated with obesity.

D) Undernutrition, at risk for malnutrition: This is incorrect because a BMI of 32 kg/m² is indicative of excess weight, not undernutrition or malnutrition. The client's BMI suggests an over-nutrition status rather than undernutrition.

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The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

Correct Answer is D

Explanation

The nurse is assessing a young adult female who is 5 feet 5 inches (165 cm) and has a body mass index (BMI) score of 32 kg/m2. Based on this BMI, what should the nurse deduce about this client's general health? Reference Range: Body Mass Index (BMI) [Normal 18.5 to 24.9 kg/m2]

Correct Answer is A

Explanation

An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply.

The nurse should anticipate difficulty locating the point of maximal impulse (PMI) in which client? Reference Range: Body mass index (BMI) Normal or healthy weight (18.5 kg/m2 to 24.9 kg/m2)]

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When evaluating a client's rectal bleeding, which findings should the nurse document?

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