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A client with fibromyalgia is in the hospital for an unrelated issue. The client reports that sleep, which is always difficult, is even harder now. What actions by the nurse are most appropriate? (Select all that apply.)
- A. Allow uninterrupted rest time
- B. Adhere to the client's usual bedtime routine
- C. Limit noise and light
- D. Offer a strong sleeping pill
- E. Provide a warm shower
Correct Answer: A,B,C,E
Rationale: Clients with fibromyalgia often have sleep disturbances, which can be exacerbated by the hospital environment. Allowing uninterrupted rest time, adhering to the client's usual bedtime routine, limiting noise and light, and offering a warm shower can help. A strong sleeping pill should be a last resort.
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A client has newly diagnosed systemic lupus erythematosus (SLE). What instruction by the nurse is most important?
- A. Be sure you get enough sleep at night
- B. Eat plenty of high-protein, high-iron foods
- C. Notify your provider at once if you get a fever
- D. Weigh yourself every day on your home scale
Correct Answer: C
Rationale: A fever is a classic sign of a lupus flare and should be reported immediately. Rest and nutrition are important but do not take priority over teaching the client what to do if they develop an elevated temperature.
A client with rheumatoid arthritis (RA) is on the postoperative nursing unit after having elective surgery. The client reports that the arm feels like pins and needles and that the neck is painful since returning from surgery. What action by the nurse is best?
- A. Assist the client to change positions
- B. Encourage range of motion of the neck
- C. Notify the provider immediately
- D. Provide pain medication as ordered
Correct Answer: C
Rationale: Clients with RA can have cervical joint involvement. This can lead to an emergent situation due to potential spinal cord compression. The nurse should notify the provider immediately to assess for this serious complication.
A client who has had systemic lupus erythematosus (SLE) for many years is in the clinic reporting hip pain with ambulation. Which action by the nurse is best?
- A. Assess if the client has been taking steroids
- B. Facilitate a consultation with physical therapy
- C. Measure the range of motion in both hips
- D. Notify the health care provider immediately
Correct Answer: A
Rationale: Steroid use is common in clients with SLE and can lead to osteonecrosis (bone necrosis). The nurse should determine if the client has been taking a steroid. Physical therapy may be beneficial, but there is not enough information about the client yet. Measuring range of motion is best done by the physical therapist. Notifying the provider immediately is not warranted.
A nurse is teaching a female client with rheumatoid arthritis (RA) about taking methotrexate (MTX) for disease control. What information does the nurse include? (Select all that apply.)
- A. Avoid acetaminophen or over-the-counter medication
- B. It may take several weeks to become effective
- C. Pregnancy and breast-feeding are not affected by MTX
- D. You may find that folic acid, a B vitamin, reduces side effects
- E. Avoid crowds and sick people
Correct Answer: A,B,D,E
Rationale: MTX is a disease-modifying antirheumatic drug and is used as a first-line drug for RA. MTX can cause liver toxicity, so the client should be advised to avoid medications that contain acetaminophen. It may take weeks to effectively treat RA. MTX can cause immunosuppression, so avoiding sick people and crowds is important. Folic acid helps reduce side effects for some people. Pregnancy and breast-feeding are contraindicated while on this drug.
A nurse is discharging a client to a short-term rehabilitation center after a joint replacement. Which action by the nurse is most important?
- A. Administering pain medication before transport
- B. Answering any last-minute questions by the client
- C. Ensuring the family has directions to the facility
- D. Providing a verbal hand-off report to the facility
Correct Answer: D
Rationale: As required by The Joint Commission and other accrediting agencies, a hand-off report must be given to the new provider to prevent error. The other options are valid responses but do not take priority.