Patient Data

Exhibits
Click to indicate which findings are indicative of rheumatoid arthritis or are not applicable to that disease. Each row must have only one response option selected.

Fatigue and fever

Pain increases with motion

Heberden nodes

Symmetrical involvement

Small joints of the hand

Joint swelling

Morning stiffness quickly resolves

Answer and Explanation

The Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"},"G":{"answers":"B"}}

Fatigue and fever – Rheumatoid Arthritis. Systemic symptoms such as fatigue and low-grade fever are common in rheumatoid arthritis (RA) due to its autoimmune inflammatory nature.

Pain increases with motion – Rheumatoid Arthritis. In RA, joint pain worsens with movement due to inflammation, though it can also occur at rest.

Heberden nodes – Not Applicable. Heberden’s nodes are bony growths on the distal interphalangeal (DIP) joints, which are characteristic of osteoarthritis (OA), not RA. RA primarily affects the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints.

Symmetrical involvement – Rheumatoid Arthritis. RA typically presents symmetrically, meaning it affects the same joints on both sides of the body.

Small joints of the hand – Rheumatoid Arthritis. RA commonly affects small joints, especially the MCP and PIP joints in the hands.

Joint swelling – Rheumatoid Arthritis. Inflammation leads to swelling in affected joints, a hallmark of RA.

Morning stiffness quickly resolves – Not Applicable. Morning stiffness in RA lasts more than 30 minutes to several hours, whereas in osteoarthritis, stiffness typically resolves quickly with movement.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Observe the client's urine for dark orange color. Dark urine may indicate jaundice due to excess bilirubin excretion, but it is not a definitive assessment method. Other conditions, such as dehydration or certain medications, can also cause urine discoloration.

B. Examine the client's sclera for icterus. The sclera is one of the first places jaundice becomes visible due to bilirubin deposition. Checking for yellow discoloration in the sclera is a reliable method to confirm jaundice, especially in clients with gallstones.

C. Assess conjunctival sacs of lower lids for pallor. Pallor in the conjunctival sacs is used to assess anemia rather than jaundice. While anemia and jaundice may coexist in some conditions, conjunctival pallor does not confirm jaundice.

D. Review recent serum bilirubin levels. While laboratory results provide an objective measure of bilirubin levels, the nurse's immediate role in assessment involves direct observation. Examining the sclera for icterus is a faster way to confirm jaundice before laboratory results are reviewed.

A. Petechiae. B. Hematoma. C. Ecchymosis. D. Vesicle.

Correct Answer is A

Explanation

A. Petechiae.Petechiae are small, round, flat, pinpoint red or purple spots caused by tiny capillary ruptures under the skin. They do not blanch with pressure and may be associated with trauma, strangulation, or clotting disorders, making this the correct term for documentation.

B. Hematoma. A hematoma is a localized collection of blood under the skin or tissues, often appearing as a raised, swollen, and discolored area. Unlike petechiae, hematomas result from larger vessel bleeding and are more prominent.

C. Ecchymosis.Ecchymosis refers to larger patches of bruising caused by blood leaking into tissues, commonly seen after blunt trauma. These areas typically change color over time as the blood is reabsorbed.

D. Vesicle. A vesicle is a small, fluid-filled blister, often associated with conditions like herpes simplex or chickenpox. Since the described spots are flat and red rather than fluid-filled, vesicle is not the correct term.

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Patient Data Exhibits Click to indicate which findings are indicative of rheumatoid arthritis or are not applicable to that disease. Each row must have only one response option selected.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client with gallstones for jaundice. Which action should the nurse perform to confirm this information?

Correct Answer is B

Explanation

The nurse is performing a head-to-toe physical examination on a known victim of intimate partner violence. The visual exam reveals several round, flat, pinpoint, red spots. How should the nurse document this finding?

Correct Answer is A

Explanation

The college health clinic nurse is preparing a seminar on testicular self-examination (TSE). Which instruction should be included in the content for this seminar?

The nurse observes that the lower legs of a client with diabetes mellitus are shiny, and with no hair growth. To obtain additional data to support these findings, which assessment should the nurse perform?

When assessing an older adult client with a history of cardiovascular disease, dyspnea, and peripheral edema, which method is best for the nurse to use to assess the client's pulse rate?

The school nurse is interviewing a 13-year-old girl who wants to go home from school because of "back pain." Which question should the nurse ask the adolescent first?

The nurse assesses a young adult female who was brought to the emergency department (ED) by her boyfriend because she has not been feeling well all day and he believes she is getting worse. Which finding supports the nurse's suspicion that the client is experiencing appendicitis?

The nurse is assessing a client who has a history of kidney stones and returns to the clinic with flank pain. Which intervention should the nurse implement first?

Patient Data

Exhibits
Click to indicate which findings are indicative of rheumatoid arthritis or are not applicable to that disease. Each row must have only one response option selected.