Clinical Scenario:
A nurse is assessing a patient who reports joint pain, morning stiffness, and difficulty gripping objects. The nurse observes bony enlargements at the distal and proximal interphalangeal joints of both hands.
Which of the following findings should the nurse document in the patient's assessment?
Tophi deposits and podagra
Heberden's nodes and Bouchard's nodes
Ulnar deviation and joint subluxation
Swan-neck deformity and Boutonnière deformity
The Correct Answer is B
A. Tophi deposits and podagra: These findings are associated with gout, not osteoarthritis. Tophi are urate crystal deposits, and podagra refers to gout affecting the big toe.
B. Heberden's nodes and Bouchard's nodes: Heberden’s nodes are bony growths at the distal interphalangeal (DIP) joints, while Bouchard’s nodes affect the proximal interphalangeal (PIP) joints. These are characteristic of osteoarthritis.
C. Ulnar deviation and joint subluxation: Ulnar deviation and joint subluxation are commonly seen in rheumatoid arthritis, not osteoarthritis.
D. Swan-neck deformity and Boutonnière deformity: These deformities are typical of rheumatoid arthritis, not osteoarthritis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. “I will reposition every 2 hours to prevent pressure injuries." Repositioning every 2 hours is a key preventive measure to relieve pressure and reduce the risk of pressure ulcers. This is an appropriate statement and does not indicate a need for further teaching.
B. “I should apply warm compresses to any red areas to improve circulation and prevent ulcers." This statement indicates a need for further teaching. Applying warm compresses to reddened areas can actually worsen tissue damage by increasing moisture and promoting skin breakdown. Instead, pressure should be relieved from the area immediately.
C. “I will encourage a diet rich in vitamin C, zinc, and protein to support skin healing." A diet high in protein, vitamin C, and zinc helps support skin integrity and promotes wound healing, making this a correct statement.
D. “I should use foam cushions and heel protectors to relieve pressure on bony prominences." Foam cushions and heel protectors help redistribute pressure, reducing the risk of pressure ulcers on bony areas like the sacrum and heels. This statement does not indicate a need for further teaching.
Correct Answer is A
Explanation
A. Full-Thickness (Third-Degree). A third-degree (full-thickness) burn destroys both the epidermis and dermis, leaving the skin dry, white, or charred. Due to nerve damage, the patient does not experience pain in the affected area.
B. Superficial (First-Degree). A first-degree burn affects only the epidermis and presents with redness, mild swelling, and pain. The skin remains intact, unlike the description provided.
C. Deep Full-Thickness (Fourth-Degree). A fourth-degree burn extends beyond the skin into muscle, bone, or fat. The description does not indicate such deep involvement.
D. Partial-Thickness (Second-Degree). A second-degree burn involves the epidermis and part of the dermis, causing blistering, redness, and pain. This is not consistent with the described dry, white, and painless presentation.
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