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The nurse is planning care in the home for a client with rheumatoid arthritis. What instruction(s) should the nurse include in the plan of care? Select all that apply.
- A. Collaborate with occupational therapists for specialized equipment.
- B. Identify the exercise regimen planned by physical therapist.
- C. Provide nursing assistance for ADLs.
- D. Teach the nursing assistant to allow extra time in the evening for hygiene or other procedures.
- E. Ensure the home environment is safe.
Correct Answer: A,B,C,E
Rationale: The nurse should collaborate with occupational therapists for specialized equipment, identify the exercise regimen planned by physical therapist, provide nursing assistance for ADLs, and ensure the home environment is safe. The nurse should teach the nursing assistant to allow extra time in the morning, not the evening, for hygiene or other procedures.
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A client with suspected osteomalacia has a fractured tibia and fibula. What test would give a definitive diagnosis of osteomalacia?
- A. A bone biopsy
- B. Demineralization of the bone
- C. Increased and decreased areas of bone metabolism
- D. Elevated levels of alkaline phosphatase
Correct Answer: A
Rationale: A definitive diagnosis is obtained by bone biopsy. Radiographic studies demonstrate demineralization of the bone. A bone scan detects increased and decreased areas of bone metabolism. Alkaline phosphatase levels are detected from a blood sample.
A client is diagnosed with osteomyelitis. This is most commonly caused by which of the following?
- A. Proteus vulgaris
- B. Pseudomonas aeruginosa
- C. Escherichia coli
- D. Staphylococcus aureus
Correct Answer: D
Rationale: Staphylococcus aureus causes over 50% of bone infections. Other organisms include Proteus vulgaris and Pseudomonas aeruginosa, as well as E. coli.
The nurse is providing teaching to a client with a mild case of bunions. Which suggestion would be most important for the nurse to give this client?
- A. Avoid strenuous exercise.
- B. Avoid foot creams.
- C. Don proper footwear.
- D. Regularly use analgesics.
Correct Answer: C
Rationale: The most important instruction a nurse should give clients with bunions or hammer toe is to don proper footwear. Low-heeled, well-fitted shoes are recommended. Regular use of analgesics is not necessary for bunions if pain is not severe and the client has little or no difficulty. The client need not avoid strenuous exercise, running, or foot creams if the footwear is appropriate.
A client is diagnosed with systemic lupus erythematosus (SLE). Which action would be most appropriate for the nurse to use to evaluate the client's stage of disease?
- A. Observe the client's gait.
- B. Review the client's medical record.
- C. Inspect the client's mouth.
- D. Ausculate the client's lung sounds.
Correct Answer: B
Rationale: The nurse evaluates the stage of SLE and plans appropriate interventions by reviewing the medical record and diagnostic findings of the client. The stage of the disease cannot be established by observing the client's gait, inspecting the client's mouth, or auscultating the client's lung sounds.
A client is receiving treatment for an acute episode of gout with colchicine. The nurse is administering the medication every 2 hours. What symptom(s) should the nurse be sure the client communicates so that the drug can be temporarily stopped? Select all that apply.
- A. Diarrhea
- B. Tingling in the arms
- C. Intestinal cramping
- D. Increase in pain in the affected extremity
- E. Nausea and vomiting
Correct Answer: A,C,E
Rationale: Colchicine is administered every 1 or 2 hours until the pain subsides or nausea, vomiting, intestinal cramping, and diarrhea develop. When one or more of these symptoms occurs, the drug should be stopped temporarily. Tingling in the arms and increase in pain are not normal adverse reactions that are seen with this drug.