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    HESI RN EXIT 3 PROCTORED EXAMQuestion 120
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    HESI RN EXIT 3 PROCTORED EXAM

    Exhibits Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.

    Explanation & Rationale

    Actions to Take: A. Educate on disease process and management: Rheumatoid arthritis (RA) is a chronic autoimmune disorder characterized by inflammation of the synovial membrane, leading to joint pain, swelling, and stiffness. Educating the client about RA helps them understand the disease, its progression, treatment options, and the importance of adherence to prescribed medications and lifestyle modifications. This empowers the client to actively participate in managing their condition and improve outcomes. B. Turn every two hours to offload bony prominences to prevent pressure injuries: Rheumatoid arthritis predisposes individuals to joint deformities and immobility due to joint inflammation and pain. Immobility increases the risk of pressure injuries, especially over bony prominences. Turning the client every two hours helps redistribute pressure, reduces the risk of pressure ulcers, and maintains skin integrity. Potential Condition: D. Rheumatoid arthritis: The client's clinical presentation, including bilateral joint pain and stiffness, positive rheumatoid factor, positive antinuclear antibody test, elevated erythrocyte sedimentation rate (ESR), and soft tissue swelling with marginal erosions on hand X-rays, is consistent with rheumatoid arthritis (RA). RA is a chronic autoimmune disease characterized by inflammation of the synovial joints, leading to joint damage, pain, and functional impairment. Parameters to Monitor: C. Pain: Monitoring pain is essential in rheumatoid arthritis management to assess the effectiveness of pain management interventions and adjust treatment accordingly. Pain assessment tools, such as numerical rating scales or visual analog scales, help quantify pain intensity and guide pain management strategies. D. Skin breakdown: Rheumatoid arthritis can limit mobility and predispose individuals to prolonged immobility, increasing the risk of pressure injuries. Monitoring for signs of skin breakdown, such as erythema, blanchable or non-blanchable skin changes, and skin integrity over bony prominences, helps prevent pressure ulcers and facilitates early intervention if skin breakdown occurs. Regularly turning the client, maintaining proper positioning, and providing adequate support surfaces are essential to prevent pressure injuries.

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