The nurse is reviewing the client's medical record.

Exhibits

For each potential nursing action, click to specify if the action is indicated or not indicated.

A. Postoperative ambulation is important for recovery and preventing complications such as deep vein thrombosis, but it is not the most critical focus in the immediate preoperative period for a client undergoing a total laryngectomy.
B. Stoma site cleaning is the priority for the nurse to reinforce. After a total laryngectomy, the client will have a permanent stoma (opening) in the neck for breathing. Proper care and cleaning of the stoma site are essential to prevent infection, maintain airway patency, and ensure the client can manage their new method of breathing effectively.
C. Pain management is an important aspect of postoperative care, but it is secondary to ensuring that the client understands how to care for their stoma. Addressing pain is essential for comfort, but it does not take precedence over the immediate care required for the stoma.
D. Coughing and deep breathing are important for maintaining lung function and preventing complications such as pneumonia after surgery, but they are not the most critical teaching point for a client who will have a stoma after a total laryngectomy. The priority should be on the specific care of the stoma to ensure safety and effective breathing postoperatively.

Potential Condition:

• Osteoarthritis is a degenerative joint disease characterized by progressive cartilage deterioration, leading to pain, stiffness, and crepitus in affected joints. The client’s symptoms of localized pain in the right knee and left wrist, along with crepitus, are hallmark features of osteoarthritis. The absence of systemic symptoms, such as fever or fatigue, further supports this diagnosis. Additionally, the client’s age and lack of widespread joint involvement are consistent with osteoarthritis rather than an inflammatory condition.

Actions to Take:

• Instruct the client to apply heat. Heat application helps relieve pain and stiffness in osteoarthritis by increasing blood flow, relaxing muscles, and reducing joint discomfort. This is particularly useful for chronic joint conditions where stiffness worsens with inactivity.
• Instruct the client to avoid foods high in purines. Although osteoarthritis itself is not directly related to uric acid levels, the client’s elevated uric acid suggests a risk for gouty arthritis. Avoiding purine-rich foods such as red meat, seafood, and alcohol can help prevent the development of gout, which could worsen joint symptoms.

Parameters to Monitor:

• Monitoring mobility is essential in osteoarthritis as it progressively worsens over time. Assessing range of motion, stiffness, and functional limitations helps guide treatment adjustments and determine whether additional interventions, such as physical therapy or assistive devices, are necessary.
• Uric acid level. The client’s uric acid level is elevated, which may indicate a predisposition to gout. Monitoring uric acid levels is important to prevent or identify early signs of gouty arthritis, which can coexist with osteoarthritis and cause episodic joint pain.

Rationale for Incorrect Options:

• Rheumatoid Arthritis is an autoimmune disorder that typically presents with symmetrical joint involvement, morning stiffness lasting more than 30 minutes, and systemic symptoms such as fatigue and weight loss. The client does not exhibit these features, and their negative antinuclear antibodies (ANA) and normal erythrocyte sedimentation rate (ESR) make rheumatoid arthritis unlikely.
• Systemic Lupus Erythematosus (SLE) is a multisystem autoimmune disorder that can cause joint pain along with systemic symptoms such as facial rashes, kidney involvement, and hematologic abnormalities. The client does not have the characteristic malar rash, widespread joint pain, or other systemic findings. Furthermore, their ANA is negative, which significantly reduces the likelihood of SLE.
• Instruct the client to avoid large crowds is not appropriate because osteoarthritis is not an autoimmune or immunosuppressive condition. Unlike rheumatoid arthritis or lupus, osteoarthritis does not increase infection risk, so there is no need to avoid crowded places.
• Instruct the client to apply cold would not be the preferred intervention for osteoarthritis. Cold therapy is generally more effective for acute inflammation, whereas heat is better for chronic joint pain and stiffness.
• Lymphadenopathy is not a concern in osteoarthritis because it is a degenerative joint disease rather than an infectious or inflammatory condition. Swollen lymph nodes are more commonly seen in infections or autoimmune diseases like lupus.
• ANA does not need to be monitored for osteoarthritis, as it is primarily used to diagnose autoimmune conditions such as lupus. The client’s ANA is already negative, further confirming that autoimmune disease is unlikely.