Which nursing responsibility is related to health promotion and teaching for the client with rheumatoid arthritis?

Choice A reason: Waiting until after the procedure to assess for discomfort does not ensure client safety during the procedure itself. While pain assessment is important, it is not the priority safety intervention in this situation, especially since the client is already mildly confused and could disrupt the sterile field or injure themselves if not properly guided.

Choice B reason:Instructing a mildly confused client to keep their hands under the sterile field is likely to be ineffective and potentially dangerous. A confused client may not be able to follow or remember complex instructions, increasing the risk of contaminating the sterile field or causing injury. Instead, a nurse or assistant should physically stay near the client's hands to guide them.

Choice C reason: Pouring cleansing solution onto the sterile cloth field would contaminate the sterile setup, since fluids should only be poured into sterile containers or basins. This action could compromise the sterile field and increase infection risk, making it unsafe practice.

Choice D reason:Verification of informed consent is a critical safety intervention that must occur before any invasive procedure. Since the client is mildly confused, the nurse must ensure that the client had the capacity to consent or that a legal proxy provided it. Proceeding without verifying consent is a legal risk and violates the client's autonomy and safety protocols.

Choice A reason: While assessing breath sounds is part of a comprehensive evaluation, it is not the most critical intervention for a TIA, which primarily affects neurological function.

Choice B reason: Palpating the suprapubic region for urinary retention is important but not the priority intervention for a client with TIA, as it does not directly relate to the risk of stroke.

Choice C reason: Reviewing the client's daily medications is necessary for overall care but is not the most immediate concern upon admission for a TIA.

Choice D reason: Initiating neurological monitoring every 2 hours is essential for a client with TIA to promptly identify any changes or progression in neurological status, which could indicate a stroke. This is the most important intervention to include in the plan of care for a client admitted with TIA. Neurological monitoring allows for immediate intervention if the client's condition worsens, potentially preventing further ischemic damage.