the client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis

ATI RN

Multi Dimensional Care | Exam | Rasmusson

1. The client asks the nurse what nonpharmacological intervention can be used to reduce pain and swelling in her joints affected by rheumatoid arthritis. What is the most appropriate response by the nurse?

A. "Ice packs can be used to reduce swelling but should be removed after 20 minutes."?
B. "Heat always makes the swelling go down. You do not need any other interventions."?
C. "Try high impact exercise exercise like running to loosen up your joints and reduce pain."?
D. "Apply ice packs. It is generally okay to keep them on for up to one hour at a time."?

Correct answer: A

Rationale:

2. A client has AIDS. Which of these findings indicate possible infection?

A. Respirations; 22 breaths per minute
B. Client ambulates 20 feet
C. Purulent drainage
D. Oxygen saturation; 97% on room air

Correct answer: C

Rationale:

3. A client is bedridden and appears to be frail and malnourished. Which nursing interventions will increase the risk of pressure injury?

A. Applying moisturizer to dry areas of the skin
B. Massaging the client's reddened shoulders and heels
C. Cleansing the skin routinely after soiling occurs
D. Using a Hoyer lift for all transfers

Correct answer: B

Rationale:

4. A nurse is teaching a client how to follow a low-purine diet as prescribed by the provider for the management of gout. What statement by the client indicates a correct understanding of the teaching?

A. "I should choose red meat instead of poultry."?
B. "I should avoid eating liver and other organ meats."?
C. I can drink only white wine."?
D. "I will need to limit the number of fruit servings each day."?

Correct answer: B

Rationale:

5. What is the priority nursing diagnosis for a client with immobility?

A. Constipation related to immobility
B. Ineffective breathing pattern related to inability to breathe deeply in a supine position
C. Risk for impaired skin integrity as evidenced by pressure over bony prominences
D. Risk for disuse syndrome as evidenced by immobility

Correct answer: C

Rationale: The correct priority nursing diagnosis for a client with immobility is 'Risk for impaired skin integrity as evidenced by pressure over bony prominences.' Immobility predisposes the client to the development of pressure ulcers due to prolonged pressure on bony areas. Monitoring and preventing impaired skin integrity is crucial to prevent complications. Choices A, B, and D are not the priority in this case. Constipation, ineffective breathing pattern, and disuse syndrome are important but secondary to the immediate risk of skin breakdown associated with immobility.