Multidimensional Care I (Rasmussen College) (MDC1)

The correct answer is B. "I will shower every day in hot water."

Explanation:

Showering every day in hot water can strip the skin of its natural oils, leading to increased dryness and irritation. Instead, individuals with xerosis should use lukewarm water, limit shower time to 10–15 minutes, and apply a moisturizer immediately after bathing to lock in moisture.

Why the Other Options Are Incorrect:

 "I will use a humidifier during the winter months."

Using a humidifier helps maintain indoor air moisture, preventing skin from becoming overly dry, especially during winter when indoor heating reduces humidity.

"I will avoid tight belts." 

Tight clothing, including belts, can rub against the skin, causing irritation and worsening dryness, particularly in individuals prone to xerosis. Avoiding tight belts is a good preventive measure.

 "I will drink at least 3000 mL of water daily."

Staying hydrated is essential for maintaining skin moisture. Adequate water intake helps support skin hydration from within, reducing the severity of dryness.

Summary:

Taking hot showers daily worsens dry skin by stripping natural oils, so this statement indicates a need for further teaching. Using a humidifier, staying hydrated, and avoiding tight clothing are appropriate strategies for preventing xerosis.

The correct answer is: D. Fibromyalgia.

Explanation:

Fibromyalgia is not a complication of rheumatoid arthritis (RA). Although both conditions involve chronic pain and fatigue, they are distinct disorders. Fibromyalgia is a neurological condition that causes widespread musculoskeletal pain, tenderness, and fatigue but does not cause joint inflammation or damage, which are hallmark features of RA. While some individuals with RA may also develop fibromyalgia, it is not a direct complication of RA.

Why the other choices are correct complications of RA:

A. Paresthesia – This is a common complication of RA due to nerve compression from joint inflammation. Carpal tunnel syndrome is particularly common in RA, causing tingling, numbness, and burning sensations in the hands and fingers. Chronic inflammation in the joints can lead to nerve irritation, resulting in paresthesia.

B. Joint deformity – One of the most significant complications of RA is joint deformity, which occurs due to chronic inflammation, cartilage destruction, and bone erosion. Over time, RA leads to permanent joint damage and misalignment, commonly seen in the hands and fingers (e.g., swan-neck deformity and boutonnière deformity). This is a key characteristic of severe, untreated RA.

C. Dry eyes – Many RA patients develop secondary Sjögren’s syndrome, an autoimmune condition that leads to dry eyes and dry mouth due to inflammation of the tear and salivary glands. This condition affects mucous membranes and can cause gritty, irritated eyes.

Summary:

The correct answer is D. Fibromyalgia, as it is a separate condition rather than a direct complication of RA. Paresthesia (A), joint deformity (B), and dry eyes (C) are all recognized complications of RA due to nerve compression, chronic inflammation, and autoimmune involvement of mucous membranes.

The correct answer is: A. “There are many adaptive devices such as grab bars, reaching tools, grasping devices, and adaptive silverware available that may help you."

Explanation:

Clients with debilitating rheumatoid arthritis (RA) often experience joint pain, stiffness, and reduced mobility, which can make daily tasks difficult. Adaptive devices help maintain independence and prevent falls or injuries. Grab bars provide stability in the bathroom. Reaching tools and grasping devices help with dressing and household tasks. Adaptive silverware can improve eating ability for clients with limited hand mobility. These modifications help increase safety and quality of life at home.

Why the other choices are incorrect:

B. “My grandfather always had problems with his arthritis, and he would tell me that it’s better to be more stoic and not let pain interrupt your life." This is incorrect because it is dismissive and not evidence-based. Pain management is essential in RA to prevent joint damage and disability. Encouraging clients to ignore pain can lead to reduced mobility and worsening joint function.

C. “Place throw rugs throughout your home. You'll enjoy how pretty they are, and you can use them to cover up power cords, so you don't trip on them.” This is incorrect because throw rugs increase fall risk, especially for clients with mobility issues. Loose rugs and covered power cords can create tripping hazards, leading to potential fractures or injuries. Instead, floors should be kept clear, and non-slip mats should be used in areas prone to moisture.

D. “Lack of home safety may be an issue of compliance. Are you being compliant with your medications?" This is incorrect because it makes an assumption about the client’s medication adherence without addressing their safety needs. While medication compliance is important, it does not directly relate to home modifications and adaptive devices that improve safety and independence. A more supportive and educational approach is needed rather than assuming noncompliance.

Summary:

The best approach is to educate the client about adaptive devices that improve home safety and independence. Adaptive tools such as grab bars, reaching devices, and specially designed utensils can help clients with debilitating rheumatoid arthritis manage daily tasks more effectively. The other choices are incorrect because they either dismiss the client’s condition, introduce safety hazards, or assume noncompliance without addressing the client’s actual needs.

The correct answer is: C. "How does this impact your role in your family?"

Explanation:

A psychosocial assessment focuses on the client’s emotional, social, and mental well-being in relation to their illness. Severe rheumatoid arthritis (RA) can significantly impact a person’s daily life, relationships, work, and mental health. Asking about family roles allows the nurse to assess the client’s emotional and social concerns, which are crucial in managing a chronic illness like RA. This question assesses how RA affects the client's identity, responsibilities, and relationships within the family. Chronic illnesses like RA often cause role changes (e.g., inability to work, needing caregiving support, or difficulty fulfilling family duties). It helps the nurse understand the client’s psychosocial stressors, coping mechanisms, and possible need for support or counseling.

Why the Other Options Are Incorrect:

A. "Tell me about what medications you are taking."

While medication use is important, this question focuses on medical history rather than psychosocial well-being. A psychosocial assessment should explore emotional and social concerns, not just treatment details.

B. "What physical limitations are you experiencing?" 

This question focuses on the physical effects of RA rather than the psychosocial impact. While understanding limitations is important, it does not fully address how the client is coping mentally or socially.

D. "What therapies are you using to reduce swelling?"

This question is treatment-focused rather than psychosocial. It assesses medical management but does not explore the client’s emotional, mental, or social well-being.

Summary:

The best psychosocial assessment question is "How does this impact your role in your family?" because it explores the client’s emotional and social challenges related to RA. The other options focus more on medical and physical aspects rather than psychosocial concerns.

The correct answer is: A. Gown and gloves.

Explanation:

Methicillin-resistant Staphylococcus aureus (MRSA) in an abdominal wound is transmitted via direct contact with the wound drainage, contaminated surfaces, or bodily fluids. Because of this, contact precautions are required. This means that a gown and gloves must be worn when entering the room to prevent transmission. A gown prevents contamination of the nurse's clothing, and gloves protect the nurse from direct contact with infectious material.

Why the Other Options Are Incorrect:

B. Sterile gloves 

Sterile gloves are used for aseptic procedures, such as dressing changes or surgeries, where sterility is essential. Checking a pulse does not require sterile technique, only standard gloves with a gown to prevent the spread of MRSA.

C. PAPR mask 

A Powered Air-Purifying Respirator (PAPR) is necessary for airborne precautions used for infections such as tuberculosis, measles, and varicella (chickenpox). Since MRSA is not an airborne infection, a PAPR is not needed.

D. Surgical mask

A surgical mask is primarily used for droplet precautions, which are necessary for infections like influenza or COVID-19 that spread through respiratory droplets. MRSA in a wound does not spread through the air but rather through direct contact, so a surgical mask is not required unless the MRSA infection is in the respiratory tract and can be spread via droplets (e.g., MRSA pneumonia). In this case, only contact precautions (gown and gloves) are necessary.

Summary:

For a client with MRSA in an abdominal wound, the appropriate personal protective equipment (PPE) includes a gown and gloves to follow contact precautions. Sterile gloves are unnecessary for non-sterile procedures, a PAPR mask is only for airborne diseases, and a surgical mask is required only for droplet precautions, which do not apply in this case.

The correct answers are:

A. Inflammation in the joints

B. Bilateral, symmetric symptoms

C. Anorexia and weight loss

E. Fever

Explanation:

Rheumatoid arthritis (RA) is a chronic autoimmune disorder that primarily affects the joints but also has systemic effects. Early signs and symptoms include joint inflammation, pain, and stiffness, typically affecting both sides of the body symmetrically. Systemic symptoms such as anorexia, weight loss, and low-grade fever are also common due to chronic inflammation and immune system activation.

Why These Answers Are Correct:

A. Inflammation in the joints 

Inflammation is one of the first signs of RA, causing joint pain, swelling, and stiffness. The immune system mistakenly attacks the synovium (joint lining), leading to progressive joint damage.

B. Bilateral, symmetric symptoms

RA characteristically affects joints symmetrically. This means that if one wrist, knee, or hand is affected, the corresponding joint on the opposite side is also likely to be involved. This symmetrical pattern differentiates RA from other types of arthritis, such as osteoarthritis, which may be unilateral.

C. Anorexia and weight loss 

Chronic inflammation in RA leads to systemic effects such as appetite loss (anorexia) and unintended weight loss. The body’s inflammatory response increases metabolic activity, contributing to weight loss.

E. Fever 

Low-grade fever can occur in early RA due to systemic inflammation and immune system activation. Although fever is not always present, many individuals with active RA experience mild elevations in body temperature, particularly during disease flares.

Why the Other Option Is Incorrect:

D. Normal erythrocyte sedimentation rate (ESR) 

ESR is typically elevated in RA due to systemic inflammation. It is used as a marker to assess disease activity and inflammation levels. A normal ESR would be unusual in active RA.

Summary:

Early symptoms of rheumatoid arthritis include joint inflammation, bilateral symmetric involvement, anorexia, weight loss, and low-grade fever. The ESR is usually elevated, not normal.

The correct answer is: B. Assessment

Explanation:

B. Assessment

This is the correct answer because assessment is the first step of the nursing process, where the nurse collects data about the patient’s condition. In this scenario, the nurse is observing and identifying a new area of skin breakdown, which is a form of data collection. The nurse’s role in the assessment phase includes gathering both subjective and objective information to determine the patient’s needs and potential health problems.

Why the other choices are incorrect:

A. Diagnosis

This is incorrect because diagnosis is the second step of the nursing process, where the nurse analyzes assessment data to identify the patient’s health problems. While skin breakdown may lead to a nursing diagnosis, simply noticing it does not constitute the diagnosis phase. The nurse must first assess the issue before making a clinical judgment.

C. Implementation

This is incorrect because implementation is the phase where the nurse takes action based on the care plan, such as administering treatments, performing interventions, or educating the patient. Noticing a new area of skin breakdown does not involve an intervention; it is an observation that occurs in the assessment phase.

D. Evaluation

This is incorrect because evaluation involves determining the effectiveness of nursing interventions and whether the patient’s condition has improved or worsened after treatment. While the nurse may evaluate the effectiveness of previous interventions for skin integrity, simply noticing a new area of breakdown is part of assessment, not evaluation.

Summary:

The nursing process begins with assessment, where the nurse collects and documents observations about the patient’s condition. Identifying a new area of skin breakdown falls under assessment because it involves gathering new data about the patient’s skin integrity. The other phases (diagnosis, implementation, and evaluation) come after assessment in the nursing process.

The correct answer is: A. A client who has just had surgery.

Explanation

A. A client who has just had surgery.

A client who has recently undergone surgery is at the highest risk of compromised immunity because surgery causes physical stress, inflammation, and potential breaks in the skin barrier. The immune system is weakened due to the body's response to trauma, anesthesia, blood loss, and potential exposure to pathogens in the hospital environment. Additionally, post-surgical clients may have drains, catheters, or wounds that provide entry points for infections. The combination of these factors makes this client highly susceptible to infections.

Explanation of Incorrect Answers:

B. A client with extreme anxiety.

Although extreme anxiety can cause physiological stress and temporarily elevate cortisol levels, which may have a mild suppressive effect on the immune system, it does not compromise immunity as significantly as surgery. Unlike physical trauma, anxiety does not create direct vulnerabilities such as open wounds or a weakened inflammatory response

C. A client who is awaiting surgery.

A client who is awaiting surgery may experience stress, but their immune system is not yet compromised unless they have an existing condition that affects immunity. The highest risk occurs after the surgery, when the body is actively healing and more vulnerable to infections.

D. A client who just delivered a baby.

While childbirth does involve physical stress, most healthy postpartum clients recover quickly, and their immune systems function normally. However, postpartum women may have a slightly increased risk of infection due to perineal tears, cesarean incisions, or exposure to hospital-acquired infections, but this risk is lower than that of a post-surgical client who has undergone major invasive procedures.

Summary:

The client at the highest risk for compromised immunity is the post-surgical client because surgery weakens the immune system, increases inflammation, and creates entry points for infection. While anxiety, awaiting surgery, and childbirth can have some impact on immunity, none of these pose as high a risk as recent surgery.

The correct answer is: C. Raise the head of the bed.

Explanation:

When a client’s oxygen saturation drops to 85%, they are experiencing hypoxemia, which requires immediate intervention to improve oxygenation. The first action should be raising the head of the bed to facilitate lung expansion and improve ventilation. This is a simple and effective intervention that can enhance oxygenation before considering more invasive measures.

Why the Other Options Are Incorrect:

A. Call the provider – Incorrect. While notifying the provider is important, it is not the first action. The nurse must intervene immediately to improve the client’s oxygenation before calling the provider. Oxygen saturation at 85% is an urgent concern, and delaying intervention could worsen the patient’s condition.

B. Place the client in the lithotomy position – Incorrect. The lithotomy position (lying on the back with legs elevated in stirrups) is used for gynecological or rectal exams and does not aid in oxygenation. This position could worsen respiratory function by restricting lung expansion.

D. Obtain pain medication – Incorrect. While pain management is important, pain medication does not directly address hypoxemia. Administering opioids, for example, could further depress respiration and worsen the client’s oxygenation.

Summary:

The priority intervention when a client has an oxygen saturation of 85% is to raise the head of the bed to improve ventilation and oxygenation. After this, additional interventions such as administering oxygen, assessing for underlying causes, and notifying the provider can be performed as needed.