Patient Data

Exhibits

Nurse analyzes the assessment findings.

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.

Morning stiffness quickly resolves

Small joints of the hand

Fatigue and fever

Joint swelling

Heberden nodes

Symmetrical involvement

Pain increases with motion

Answer and Explanation

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

Morning stiffness quickly resolves:

Rheumatoid Arthritis: Morning stiffness is a hallmark of rheumatoid arthritis, although it typically lasts more than just a brief period.

Small joints of the hand:

Rheumatoid Arthritis: Rheumatoid arthritis commonly affects the small joints of the hands and wrists, leading to pain, stiffness, and swelling.

Fatigue and fever:

Rheumatoid Arthritis: Systemic symptoms like fatigue and low-grade fever are often associated with rheumatoid arthritis due to its inflammatory nature.

Joint swelling:

Rheumatoid Arthritis: Swelling of the joints is a key symptom of rheumatoid arthritis, typically due to inflammation and fluid accumulation within the joint.

Heberden nodes:

Not Applicable: Heberden nodes are associated with osteoarthritis, not rheumatoid arthritis. These nodes occur at the distal interphalangeal joints.

Symmetrical involvement:

Rheumatoid Arthritis: One of the classic features of rheumatoid arthritis is symmetrical involvement of joints, particularly in the hands and wrists.

Pain increases with motion:

Rheumatoid Arthritis: Joint pain that increases with motion is a common symptom of rheumatoid arthritis, reflecting active inflammation in the joints.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. This is not specific for egophony. While lung auscultation is part of a thorough assessment, egophony is assessed when the patient vocalizes a specific sound, not just breathing in and out.
B. This is a technique used to assess for whispered pectoriloquy, not egophony. The nurse would be looking for clarity of the whispered words, which is different from assessing for egophony.
C. This test is used to assess for bronchophony, where the nurse listens for clarity or increased volume of spoken words over the lungs. It is not related to egophony, which is a change in the sound when the client says "E."
D. This is the correct method for assessing egophony. In this test, the client is asked to say "E," and the nurse listens for any change in the sound. Normally, the "E" should sound like "E." If it sounds like "A," it indicates egophony, which can suggest a lung consolidation, such as might occur with a lung abscess.

A. Brudzinski reflexes B. Muscle tone C. Romberg's test D. Level of consciousness E. Pupil size F. Cranial nerves G. Glasgow coma scale

Correct Answer is ["B","C","D","E","F","G"]

Explanation

A. Brudzinski reflexes test is primarily used to assess for meningeal irritation, which is not directly related to stroke.
B. Muscle tone assessments help to identify abnormalities in motor function, which could indicate neurological damage. Given the patient’s history and the recent fall, muscle tone should be checked for any signs of weakness or spasticity.
C. This test evaluates the client’s balance and proprioception. It is a quick way to check for potential issues with the nervous system, such as ataxia or other motor impairments, which could be present in a client with a stroke.
D. Assessing the level of consciousness is critical in a neurological assessment to ensure that the client is oriented and alert, which is especially important after a fall or stroke-like symptoms.
E. Pupillary response is an essential part of a neurological exam. Checking the size and reactivity of the pupils helps to assess brainstem function and overall neurological health.
F. Cranial nerve function should be assessed to evaluate for signs of neurological deficits. In stroke patients, cranial nerve impairments can provide important diagnostic information.
G. The Glasgow Coma Scale (GCS) is a standard tool for assessing the level of consciousness and neurological status. It can provide valuable insights into the severity of a neurological condition, especially in post-fall or post-stroke patients.

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Patient Data Exhibits Nurse analyzes the assessment findings. 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

To assess for the presence of egophony, which instruction should the nurse give the client who has a lung abscess?

Correct Answer is D

Explanation

Patient Data Exhibits The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment. Which assessment(s) should the nurse conduct? Select all that apply.

Correct Answer is ["B","C","D","E","F","G"]

Explanation

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

When preparing a female client for an abdominal examination, the nurse should provide her with which instruction?

The nurse plans to assess a client's ability to think abstractly. Which question or statement is likely to provide the best information about the client's abstract thinking?

Which finding, obtained during a skin assessment, should the school nurse report to the healthcare provider?

The nurse learns in report that a client is stuporous. Which assessment should the nurse perform to confirm this report?

The nurse is obtaining a health history for a client during an annual physical examination. When evaluating the client for menopausal symptoms, which finding indicates the client is perimenopausal?

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?

While conducting a physical assessment, the nurse shines a pen light into a client's right eye and moves the light source to check the client's left eye. Which finding indicates the need for further evaluation?

Patient Data

Exhibits

Nurse analyzes the assessment findings.

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.