During a health assessment, the client reports being treated for osteoarthritis. The nurse examines the client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?
Distal interphalangeal joint nodules that deviate.
Proximal intertarsal joint swelling of big toe.
Frozen, non-movable phalangeal joints.
Non-painful enlarged interphalangeal joints.
The Correct Answer is D
A. Distal interphalangeal joint nodules that deviate: While Heberden's nodes can cause some stiffness or limited movement, "deviate" implies a significant bend or dislocation, which is not a typical characteristic of Heberden's nodes.
B. Proximal intertarsal joint swelling of big toe: This describes a swollen joint at the base of the big toe (likely gout) and is not related to Heberden's nodes, which affect the fingers.
C. Frozen, non-movable phalangeal joints: Heberden's nodes do not cause joints to become frozen or immobile. This description more accurately fits conditions like severe arthritis or advanced stages of rheumatoid arthritis where joint mobility can be significantly impaired
D. Non-painful enlarged distal interphalangeal (DIP) joints: This accurately describes Heberden's nodes, which are bony growths that typically occur on the DIP joints (closest to the fingertip) and are often painless in the early stages
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Multiple maculopapular pustules over forehead and chin on an adolescent student: These pustules could be indicative of an infectious process, such as acne or impetigo. While not necessarily an emergency, it’s important to assess and potentially treat these skin lesions promptly. The school nurse should report this to the healthcare provider for further evaluation.
B. Red, swollen, painful nodule located on the upper back of a school-aged student: This finding raises concern for an abscess or localized infection. The pain, redness, and swelling suggest an inflammatory process. The nurse should promptly report this to the healthcare provider for assessment and appropriate management.
C. Small, white flecks on the hair shafts throughout the scalp on a school-aged child: These white flecks are likely nits (lice eggs). While not an emergency, they do require attention. The nurse should inform the parents or guardians and recommend appropriate treatment. However, this finding does not necessitate immediate reporting to the healthcare provider.
D. Bilateral patellar abrasions with eschar formation on a preschool-aged student: Abrasions with eschar (dead tissue) formation can indicate a deeper injury. The nurse should report this to the healthcare provider promptly for assessment and wound care recommendations.
Correct Answer is B
Explanation
A. Use an interpreter throughout the client's hospitalization. Consistently using an interpreter throughout the client's hospitalization ensures clear communication, improves understanding, and enhances the quality of care. However, this answer does not address the specific context of the health assessment interview.
B. Maintain eye contact with client when questions are asked. Maintaining eye contact with the client rather than the interpreter helps build rapport and shows respect and engagement with the client. This practice encourages the client to feel directly involved in the conversation, even though an interpreter is present, fostering a sense of trust and comfort.
C. Ask the interpreter to tell the client to write down questions. This option may be less effective if the client has limited literacy or is uncomfortable with writing. Additionally, it adds an unnecessary step that can complicate the communication process.
D. Give the interpreter a form that lists the interview questions. Providing the interpreter with a list of questions might help streamline the process but can depersonalize the interaction and reduce the engagement with the client. It is more effective for the nurse to ask questions directly and maintain communication with the client.
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