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Sas 33

The document describes symptoms of rheumatoid arthritis including early morning stiffness, stiffness after sitting, limited range of motion, and deformed joints. It states that the most appropriate nursing diagnosis for a client complaining of these symptoms is activity intolerance related to fatigue and pain. Nursing interventions should focus on helping the client conserve energy and decrease fatigue. Over time, the client may develop ineffective coping or body image issues as the condition becomes chronic.

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Sistine Rose Labajo
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114 views

Sas 33

The document describes symptoms of rheumatoid arthritis including early morning stiffness, stiffness after sitting, limited range of motion, and deformed joints. It states that the most appropriate nursing diagnosis for a client complaining of these symptoms is activity intolerance related to fatigue and pain. Nursing interventions should focus on helping the client conserve energy and decrease fatigue. Over time, the client may develop ineffective coping or body image issues as the condition becomes chronic.

Uploaded by

Sistine Rose Labajo
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
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SAS 33

1. C

Initially, most clients with early symptoms of rheumatoid arthritis complain


of early morning stiffness or stiffness after sitting still for a while. Later
symptoms of rheumatoid arthritis include limited joint range of motion;
deformed joints, especially of the hand; and rheumatoid nodules.

2. A

Based on the client's complaints, the most appropriate nursing diagnosis


would be Activity intolerance related to fatigue and pain. Nursing
interventions would focus on helping the client conserve energy and
decrease episodes of fatigue. Although the client may develop a self-care
deficit related to the activity intolerance and increasing joint pain, the client
is voicing concerns about household chores and difficulty around the house
and yard, not self-care issues. Over time, the client may develop ineffective
coping or body image disturbance as the disorder becomes chronic with
increasing pain and fatigue.

3. A B D

Based on the client's complaints, the most appropriate nursing diagnosis


would be Activity intolerance related to fatigue and pain. Nursing
interventions would focus on helping the client conserve energy and
decrease episodes of fatigue. Although the client may develop a self-care
deficit related to the activity intolerance and increasing joint pain, the client
is voicing concerns about household chores and difficulty around the house
and yard, not self-care issues. Over time, the client may develop ineffective
coping or body image disturbance as the disorder becomes chronic with
increasing pain and fatigue.

4. C

Maintaining usual ways of accomplishing tasks would be the lowest priority


during the acute phase. Rather, the focus is on developing less stressful
ways of accomplishing routine tasks. Pain relief is a high priority during the
acute phase because pain is typically severe and interferes with the client's
ability to function. Preserving joint function and preventing joint deformity
are high priorities during the acute phase to promote an optimal level of
functioning and reduce the risk of contractures.
5. A B E

An arthrocentesis is performed to aspirate excess synovial fluid, pus, or


blood from a joint cavity to relieve pain or to diagnosis inflammatory
diseases such as rheumatoid arthritis. A local agent may be used to
decrease the pain of the needle insertion through the skin and into the joint
cavity. Aspiration of the fluid into the syringe can be very painful because of
the size and inflammation of the joint. Usually a steroid medication is
injected locally to alleviate the inflammation; a compression bandage is
applied to help decrease swelling; and the client is asked to rest the joint for
up to 24 hours afterwards to help relieve the pain and promote rest to the
inflamed joint. The client may experience pain during this time until the
inflammation begins to resolve and swelling decreases.

6. A D E

To prepare a client for an arthrocentesis, the nurse should tell the client that
a local anesthetic administered by the physician will decrease discomfort.
There may be bleeding after the procedure, so the nurse should check the
dressing. The client may experience pain. The nurse should offer pain
medication and evaluate outcomes for pain relief. Because a local anesthetic
is used, the client will not require preoperative medication. The client will
rest the knee for 24 hours and then should begin range-of-motion and
muscle strengthening exercises.

7. A

Shorter sessions will allow the client to rest between the sessions. Changing
the physician's order to a different examination will not provide the
information needed for this client's treatment. Acetaminophen is a nonopioid
analgesic and an antipyretic, not an anti-inflammatory agent. Thus, it would
not help this client avoid the adverse effects of a lengthy X-ray examination.
Although the X-ray table is hard, there are other options for making the
client comfortable, rather than canceling the examination.

8. D
Osteoarthritis is a degenerative joint disease with local manifestations such
as local joint pain, unlike rheumatoid arthritis, which has systemic
manifestation such as anemia and osteoporosis. Weight loss occurs in
rheumatoid arthritis, whereas most clients with osteoarthritis are
overweight.

9. A C E

A patient with gout should avoid foods high in PURINES. These include most
red meats, organ meats (liver, kidneys, sweetbreads), alcohol (especially
beer).

10. B

Gout is due to high levels of uric acid in the blood. This can either be due to
the kidney's inability to excrete uric acid out of the body or the body is
producing too much uric acid. Some causes that can lead to increased uric
acid levels include: being overweight (BMI >25 is considered overweight),
usage of aspirin or diuretics (thiazides (hydrochlorothiazide) or loop), HIGH
consumption of purines, dehydration, renal problems. Option B is the only
patient MOST at risk for developing gout.

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