While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?

Discuss approaches to chronic pain control with the client.

Review the client's dietary intake of high-protein foods.

Notify the healthcare provider of the finding immediately.

Assess the client's radial pulses and capillary refill time.

Answer and Explanation

The Correct Answer is A

A. Discuss approaches to chronic pain control with the client:
This is the correct answer. Heberden's nodes are bony enlargements that can occur in osteoarthritis, particularly in the joints of the fingers. These nodes can be associated with pain. Discussing approaches to chronic pain control with the client is an appropriate nursing intervention to address the client's pain and improve quality of life.

B. Review the client's dietary intake of high-protein foods:
Dietary intake of high-protein foods is not directly related to the management of Heberden's nodes in degenerative joint disease. Pain control and joint protection measures are more relevant.

C. Notify the healthcare provider of the finding immediately:
While it's important to communicate significant findings to the healthcare provider, the presence of Heberden's nodes in degenerative joint disease may not require immediate notification unless there are other concerning symptoms or complications.

D. Assess the client's radial pulses and capillary refill time:
Assessing radial pulses and capillary refill time is not directly related to managing Heberden's nodes in degenerative joint disease. These nodes are primarily a result of joint changes in osteoarthritis.

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Correct Answer is B

Explanation

A. Activity level of bowel sounds:
Bowel sounds are important to assess, but they may not directly influence or be influenced by the abdominal pain associated with chronic pancreatitis.

B. Eating patterns and dietary intake.
Clients with chronic pancreatitis often experience abdominal pain exacerbated by the intake of food, especially fatty meals. Monitoring the client's eating patterns and dietary intake is crucial for identifying triggers that may worsen the abdominal pain. By understanding the relationship between food intake and pain, the nurse can provide guidance on dietary modifications to help manage the symptoms.

C. Level and amount of physical activity:
While physical activity is important for overall health, it may not be the primary factor contributing to or alleviating the abdominal pain in a client with chronic pancreatitis.

D. Color and consistency of feces:
Monitoring the color and consistency of feces is important for assessing pancreatic function, but it may not be the most immediate factor to address in the context of managing abdominal pain. Dietary patterns are more directly related to pain management in this case.

A. Measure the client's blood pressure. B. Remove all of the morphine patches. C. Apply oxygen per face mask. D. Administer a narcotic antagonist.

Correct Answer is D

Explanation

A. Measure the client's blood pressure:
While monitoring blood pressure is an important aspect of assessing a client's overall condition, it is not the immediate priority in a suspected opioid overdose. Respiratory depression and difficulty in arousing are more critical concerns that warrant prompt intervention with naloxone.

B. Remove all of the morphine patches:
While eventually, the nurse will need to address the presence of multiple morphine patches, removing them is not the first action. Administering naloxone to reverse the opioid effects takes precedence over patch removal.

C. Apply oxygen per face mask:
While providing oxygen may be necessary to support respiratory function, it doesn't address the underlying cause of the respiratory distress, which is likely opioid toxicity. Administering naloxone is the more direct and immediate intervention to counteract the effects of the opioids.

D. Administer a narcotic antagonist:
This is the correct and immediate priority. If the client is difficult to arouse and has multiple morphine patches, it raises concerns about opioid toxicity. Naloxone is a narcotic antagonist that can reverse the effects of opioid overdose, particularly respiratory depression, and is crucial in this scenario to restore normal respiratory function.

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While assessing a client with degenerative joint disease, the nurse observes Heberden's nodes, large prominences on the client's fingers that are reddened. The client reports that the nodes are painful. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a client with chronic pancreatitis who reports persistent gnawing abdominal pain. To help the client manage the pain, which assessment data is most important for the nurse to obtain?

Correct Answer is B

Explanation

A client with lung cancer who wears a subcutaneous morphine sulfate patch for pain is short of breath and is difficult to arouse. When performing a head to toe assessment, the nurse discovers four analgesic patches on the client's body. Which intervention should the nurse implement first?

Correct Answer is D

Explanation

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