A client with an acute exacerbation of rheumatoid arthritis (RA) has localized pain and inflammation of the fingers and feet; swelling, redness, and restricted joint motion; and reports feeling fatigued. Which nursing diagnosis has the highest priority for this client?

Correct Answer: A

Rationale: The correct answer is A) Pain related to joint inflammation. In this case, the highest priority nursing diagnosis is addressing the client's pain related to joint inflammation. Pain management is crucial in providing comfort and improving the overall well-being of the client. Pain can significantly impact the client's quality of life, mobility, and ability to engage in daily activities. By effectively managing pain, the client can experience relief, improved mobility, and better adherence to treatment plans. Option B) Impaired physical mobility may be a concern for a client with RA, but in this scenario, addressing the pain is the priority as it directly impacts mobility. Option C) Risk for infection and Option D) Disturbed sleep pattern are not the immediate priorities compared to managing the client's pain and inflammation. In an educational context, understanding the principles of prioritization in nursing care is essential. By identifying the most urgent nursing diagnosis, nurses can effectively allocate resources and interventions to address the client's most critical needs first, ensuring optimal outcomes and patient-centered care.

Correct Answer: D

Rationale: In the case of an adult client admitted with flank pain and diagnosed with acute pyelonephritis, the priority nursing action is to administer IV antibiotics as prescribed (Option D). This is because acute pyelonephritis is a bacterial infection of the kidneys that requires prompt antibiotic treatment to prevent complications such as sepsis or kidney damage. Administering antibiotics promptly is crucial to start combating the infection and prevent its progression. A) Auscultating for the presence of bowel sounds (Option A) is not the priority in this situation as the main concern is addressing the underlying infection in the kidneys. B) Monitoring hemoglobin and hematocrit (Option B) is important for assessing for anemia or blood loss, but it is not the priority in the immediate management of acute pyelonephritis. C) Encouraging turning and deep breathing (Option C) is a general nursing intervention to promote lung expansion and prevent respiratory complications but is not the priority action when dealing with a bacterial infection like pyelonephritis. In an educational context, it is essential for nursing students to understand the principles of prioritizing nursing actions based on the client's condition and needs. Understanding the pathophysiology of conditions like acute pyelonephritis and the rationale behind specific interventions helps students develop critical thinking skills and clinical judgment necessary for providing safe and effective patient care.

Correct Answer: B

Rationale: In pediatric cardiovascular nursing, monitoring intake and output is crucial in managing infants with heart failure on diuretic therapy. The most appropriate method to assess urine output in an infant is by weighing the diapers. This method allows for a non-invasive and continuous measurement of urine output, which is essential in detecting early signs of fluid imbalance in these vulnerable patients. Option A, inserting a foley catheter, is invasive and increases the risk of infection, especially in infants. It is not the first-line method for assessing urine output in this population. Option C, comparing intake with output, is important for overall fluid balance assessment but may not provide real-time information on urine output, which is crucial in infants with heart failure. Option D, measuring the amount of water added to the formula, does not directly measure urine output and may not accurately reflect the infant's true fluid status. Educationally, understanding the rationale behind choosing the appropriate method to assess urine output in infants with heart failure not only ensures accurate monitoring but also promotes safe and effective nursing care tailored to the specific needs of pediatric patients with cardiovascular conditions.

Correct Answer: A

Rationale: In the context of pediatric cardiovascular nursing, understanding the management of congenital heart defects like hypoplastic left heart syndrome is crucial. The correct answer to the question is A) Prostaglandin E. Prostaglandin E is given to keep the patent ductus arteriosus (PDA) open in infants with critical congenital heart defects, including hypoplastic left heart syndrome, to maintain pulmonary or systemic blood flow until surgical intervention can be performed. Indomethacin and ibuprofen, options B and C, are nonsteroidal anti-inflammatory drugs (NSAIDs) that are used to close a PDA by inhibiting prostaglandin synthesis. Therefore, they would be contraindicated in this scenario when we want to keep the PDA open. Digoxin, option D, is a medication commonly used in pediatric cardiology to treat heart failure by improving cardiac contractility. However, it is not the appropriate choice for keeping the PDA open in hypoplastic left heart syndrome. Educationally, it is essential for pediatric nurses to understand the rationale behind using specific medications in pediatric cardiovascular conditions to provide safe and effective care to this vulnerable population. Recognizing the pharmacological management of congenital heart defects and the medications involved is crucial for optimizing patient outcomes and preparing for potential complications.

Correct Answer: C

Rationale: In pediatric cardiovascular nursing, understanding acquired heart diseases is crucial for providing effective care. In this question, the correct answer is C) Rheumatic fever (RF). Rheumatic fever is an acquired heart disease that affects the heart, joints, skin, and brain. It is a systemic inflammatory disease that can result from inadequately treated streptococcal infections. Rheumatic fever can lead to permanent damage to the heart valves, causing rheumatic heart disease. Option A) Infective endocarditis is primarily an infection of the heart valves or inner lining of the heart chambers. While it can lead to acquired heart disease, it is not a direct example of acquired heart disease. Option B) Coarctation of the aorta is a congenital heart defect, not an acquired heart disease. It involves a narrowing of the aorta, which is present at birth. Option D) Cardiomyopathy is a disease of the heart muscle, which can be either acquired or inherited. However, in the context of this question focusing on acquired heart diseases, it is not a direct example. Understanding the differences between acquired and congenital heart diseases is essential in pediatric cardiovascular nursing to accurately diagnose and manage conditions in young patients. Recognizing the etiology, symptoms, and implications of acquired heart diseases like rheumatic fever is crucial for providing comprehensive care to pediatric patients with cardiovascular conditions.