Patient Data
Which technique should the nurse use when assessing the client for early signs of rheumatoid arthritis?
Palpate the lymph nodes.
Observe the client's fingers.
Palpate large joints for nodules.
Observe the skin for lesions.
The Correct Answer is B
B Early signs of rheumatoid arthritis often manifest in the small joints of the hands and fingers. Common findings may include swelling, redness, warmth, and stiffness in these joints. Therefore, observing the client's fingers for any signs of inflammation or deformity can provide valuable clues for early detection of rheumatoid arthritis.
A Swollen lymph node may occur in certain types of arthritis, such as reactive arthritis but they are not typically a hallmark sign of rheumatoid arthritis.
C Rheumatoid nodules can develop in later stages of rheumatoid arthritis, but they are not typically present in the early stages of the disease.
D Rheumatoid arthritis is an autoimmune disease that can affect multiple organ systems, including the skin but characteristic skin lesions are not typically associated with the early stages of the condition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
C. Type I hypersensitivity reactions, also known as immediate hypersensitivity reactions, involve the production of IgE antibodies in response to an allergen. In this case, the bee sting likely triggered an IgE-mediated immune response, leading to the release of inflammatory mediators such as histamine. The client's symptoms of body rash, shortness of breath, tachycardia, and hypotension are characteristic of anaphylaxis, which is a severe and potentially life-threatening manifestation of Type I hypersensitivity reactions.
A.. Type II hypersensitivity reactions occur when the immune system targets antigens on the body's own cells, leading to cell destruction or dysfunction.
B. Autoimmune responses involve the immune system mistakenly attacking the body's own tissues and organs, leading to inflammation and tissue damage.
D. Cell-mediated hypersensitivity reactions involve the activation of T cells and the release of cytokines, resulting in inflammation and tissue damage. Examples include delayed-type hypersensitivity reactions such as contact dermatitis or tuberculin skin testing reactions.
Correct Answer is D
Explanation
D A stool softener can help prevent straining during bowel movements, which could increase intraocular pressure and potentially harm the surgical site. Additionally, the nurse should advise the client to avoid activities that could increase pressure in the eye, such as bending at the waist, lifting heavy objects, or engaging in strenuous activities for a certain period post-surgery.
A Monitoring for changes in pupillary sizes is not specific to this type of surgery.
B Turn, cough, and deep breathe every 2 hours: This instruction is more relevant for clients who have undergone surgery or are at risk of developing respiratory complications, such as pneumonia. It is not specifically related to cataract extraction with a lens implant.
C Clients are usually advised to sleep with the head elevated or to avoid lying on the operative side to minimize the risk of intraocular pressure changes and discomfort.
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