Nokea
The nurse is teaching a patient diagnosed with progressive systemic sclerosis about health maintenance activities. Which of the following patient statements indicates the need for additional instruction?
- A. I should lie down for an hour after meals.
- B. Paraffin baths can be used to help my hands.
- C. Lotions will help if I rub them in for a long time.
- D. I should perform range-of-motion exercises daily.
Correct Answer: A
Rationale: Because of the esophageal scarring, patients should sit up for 2 hours after eating. The other patient statements are correct and indicate that the teaching has been effective.
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The nurse is teaching a patient with osteoarthritis (OA) of the left hip and knee about management of OA. Which of the following patient statements indicate a need for further education?
- A. I can take glucosamine to help decrease my knee pain.
- B. I will take 1 g of acetaminophen every 4 hours.
- C. I will take a shower in the morning to help relieve stiffness.
- D. I can use a cane to decrease the pressure and pain in my hip.
Correct Answer: B
Rationale: No more than 4 g of acetaminophen should be taken daily to avoid liver toxicity. The other patient statements are correct and indicate good understanding of OA management.
The nurse is conducting patient teaching with a patient who has systemic lupus erythematosus and is prescribed hydroxychloroquine. Which of the following information should the nurse include in the teaching plan?
- A. Has a rapid therapeutic response.
- B. Vision assessment every 6-12 months
- C. Does not prevent flare-ups of symptoms.
- D. Can only be administered intravenously.
Correct Answer: B
Rationale: Fundoscopic and visual field examinations must be performed by an ophthalmologist every 6-12 months when patients are on hydroxychloroquine. Hydroxychloroquine is often used to treat fatigue and moderate skin and joint problems. Unlike the rapid response noted with corticosteroids, effects of antimalarial therapy may not be noticed for several months. Flares may also be prevented with these drugs.
The nurse is caring for a patient with systemic lupus erythematosus (SLE) who has a facial rash and alopecia who tells the nurse, 'I hate the way I look! I never go anywhere except here to the health clinic.' Which of the following is an appropriate nursing diagnosis for the patient?
- A. Activity intolerance related to immobility
- B. Impaired social interaction related to insufficient knowledge about how to enhance mutuality
- C. Impaired skin integrity related to excretions
- D. Social isolation related to difficulty establishing relationships (embarrassment about the effects of SLE)
Correct Answer: D
Rationale: The patient's statement about not going anywhere because they hate the way they look supports the diagnosis of social isolation because of embarrassment about the effects of the SLE. Activity intolerance is a possible problem for patients with SLE, but the information about this patient does not support this as a diagnosis. The rash with SLE is nonpruritic. There is no evidence of lack of social skills for this patient.
While working at a clinic at a summer camp, the nurse sees a camper complaining of chills and muscle aches. Upon examination, the nurse notes a circular lesion with a red border and a clear centre on the camper's right arm. Which of the following actions should the nurse take next?
- A. Palpate the abdomen.
- B. Auscultate the heart sounds.
- C. Ask the patient about recent outdoor activities.
- D. Question the patient about immunization history.
Correct Answer: C
Rationale: The patient's clinical manifestations suggest possible Lyme disease. A history of recent outdoor activities such as hikes will help confirm the diagnosis. The patient's symptoms do not suggest cardiac or abdominal problems or lack of immunization.
The nurse is caring for a young adult patient suspected of having septic arthritis, is hospitalized with a fever and red, hot, painful knees. Which of the following information obtained during the nursing history indicates a risk factor for septic arthritis?
- A. Has a parent who has reactive arthritis.
- B. Is sexually active and has multiple partners.
- C. Recently returned from a trip to South America.
- D. Had several sports-related knee injuries as a teenager.
Correct Answer: B
Rationale: Neisseria gonorrhoeae is the most common cause for septic arthritis in sexually active young adults. The other information does not point to any risk for septic arthritis.