Which technique should the nurse use when assessing the client for early signs of rheumatoid arthritis?

Observe the skin for lesions.

Palpate the lymph nodes.

Palpate large joints for nodules.

Observe the client’s fingers.

Answer and Explanation

The Correct Answer is D

Choice A rationale:

Observing the skin for lesions is not a specific technique for assessing early signs of rheumatoid arthritis. While RA can sometimes manifest with skin lesions, they are not typically present in the early stages of the disease. Moreover, skin lesions can be indicative of a wide range of other conditions, making them a less reliable indicator of RA.

Choice B rationale:

Palpating the lymph nodes is also not a specific technique for assessing early signs of rheumatoid arthritis. Lymph node enlargement can occur in various inflammatory conditions, including infections and autoimmune diseases. It is not a characteristic feature of early RA.

Choice C rationale:

Palpating large joints for nodules is a technique used to assess for rheumatoid arthritis, but it is more likely to detect nodules in later stages of the disease. Nodules are typically firm, non-tender bumps that develop under the skin around joints. They are often found in areas like the elbows, knuckles, and fingers. However, they may not be present in the early stages of RA.

Choice D rationale:

Observing the client's fingers is the most appropriate technique for assessing early signs of rheumatoid arthritis. This is because the fingers are often the first joints to be affected by the disease. Early signs of RA in the fingers can include:

Swelling of the finger joints, particularly the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints. Tenderness and pain in the finger joints, especially upon movement.

Stiffness in the finger joints, which is often worse in the mornings and after periods of inactivity. Redness or warmth in the finger joints.

Difficulty bending or straightening the fingers.

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Correct Answer is B

Explanation

Choice A rationale:

While teaching the client about infection prevention measures is important, it is not the most crucial action in this situation. The client is already exhibiting symptoms and has potentially been spreading the virus.

Focusing on isolation at this point is a more effective way to prevent further transmission.

Additionally, the client may be too ill to fully comprehend or adhere to instructions regarding masks, handwashing, and social distancing.

Choice B rationale:

Isolation is the most essential action to prevent the spread of COVID-19 to others. This is because:

COVID-19 is highly contagious and can spread through respiratory droplets produced when an infected person coughs, sneezes, or talks.

Isolation physically separates the infected person from others, reducing the risk of transmission.

Proper PPE, such as gloves, gowns, masks, and eye protection, creates a barrier between the healthcare worker and the infectious droplets, further minimizing the risk of spread.

Choice C rationale:

Reporting the COVID-19 result to the local health department is important for tracking and managing the spread of the virus. However, it is not as immediate a priority as isolating the client to prevent further transmission.

Choice D rationale:

Counseling family members about monitoring for symptoms is also important for early identification and containment of potential cases. However, it does not directly address the immediate risk of transmission from the actively symptomatic client.

A. Dysrhythmia B. Toxicity C. Anemia D. Pneumonia

Correct Answer is D

Explanation

Rationale for Choice A: Dysrhythmia

There is no information in the question stem to suggest that the patient is experiencing a dysrhythmia.

Dysrhythmias are abnormal heart rhythms that can be caused by a variety of factors, including heart disease, electrolyte imbalances, and medications.

While it is possible that the patient could develop a dysrhythmia as a complication of pneumonia, there is no evidence to support this in the given information.

Additionally, enalapril, which the patient is taking for hypertension, is not typically associated with an increased risk of dysrhythmias.

Rationale for Choice B: Toxicity

There is no information in the question stem to suggest that the patient is experiencing toxicity.

Toxicity can be caused by a variety of substances, including medications, drugs, and environmental toxins.

While it is possible that the patient could develop toxicity as a complication of pneumonia, there is no evidence to support this in the given information.

Additionally, the patient's medication regimen of enalapril and a multivitamin is not typically associated with an increased risk of toxicity.

Rationale for Choice C: Anemia

There is no information in the question stem to suggest that the patient is anemic.

Anemia is a condition in which there is a decreased number of red blood cells or hemoglobin in the blood.

While it is possible that the patient could develop anemia as a complication of pneumonia, there is no evidence to support this in the given information.

Additionally, the patient's surgical history of adenoid removal and a fractured tibia is not typically associated with an increased risk of anemia.

Rationale for Choice D: Pneumonia

The patient is a 51-year-old male with a diagnosis of pneumonia.

Pneumonia is an infection of the lungs that can be caused by bacteria, viruses, or fungi.

The patient's symptoms, such as cough, fever, and difficulty breathing, are all consistent with a diagnosis of pneumonia.

Additionally, the patient's medical history of hypertension does not rule out pneumonia, and in fact, some studies have shown that hypertension may be a risk factor for developing pneumonia.

Therefore, pneumonia is the most likely condition that the patient has based on the information provided.

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Which technique should the nurse use when assessing the client for early signs of rheumatoid arthritis?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client presents to the emergency department with muscle aches, headache, fever, and describes a recent loss of taste and smell.The nurse obtains a nasal swab for COVID-19 testing. Which action is most important for the nurse to take?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

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