While assessing a patient with degenerative joint disease, the nurse notices Heberden’s nodes, and large prominences on the patient’s fingers that are reddened and painful.
What should the nurse do?
Discuss strategies for managing chronic pain with the patient.
Check the patient’s radial pulses and capillary refill time.
Immediately notify the healthcare provider of the finding.
Review the patient’s dietary intake of high-protein foods.
The Correct Answer is A
Choice A rationale
Heberden’s nodes are bony swellings that develop at the end joints (distal interphalangeal joints) of fingers, particularly the fingers closest to the nails. They are a characteristic feature of osteoarthritis, a degenerative joint disease. Osteoarthritis causes the protective cartilage in the joints to wear down over time, leading to the development of these bony growths, which can be painful and limit joint movement. Therefore, discussing strategies for managing chronic pain with the patient is the most appropriate action for the nurse to take.
Choice B rationale
While checking the patient’s radial pulses and capillary refill time is a part of a comprehensive physical assessment, it is not directly related to the management of Heberden’s nodes or osteoarthritis.
Choice C rationale
Although Heberden’s nodes are a sign of osteoarthritis, they are not typically an emergency that requires immediate notification of the healthcare provider. They are a common finding in individuals with osteoarthritis and are usually managed with conservative measures such as pain management and physical therapy.
Choice D rationale
Reviewing the patient’s dietary intake of high-protein foods is not directly related to the management of Heberden’s nodes or osteoarthritis. While a balanced diet is important for overall health, it does not specifically address the pain and limited joint movement associated with Heberden’s nodes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While lean beef, salads, and baked potatoes can be part of a balanced diet, they do not specifically target the prevention of colon and rectal cancers. Red meat, in particular, has been associated with an increased risk of colorectal cancer.
Choice B rationale
Potatoes, low-fat breads, and applesauce can be part of a balanced diet, but they do not specifically target the prevention of colon and rectal cancers. A diet rich in whole grains, fruits, and vegetables is more beneficial.
Choice C rationale
A diet rich in oatmeal, raisins, and fruit with skin is high in fiber and antioxidants, which can help reduce the risk of colon and rectal cancers. This is especially important for clients with a strong family history of these cancers.
Choice D rationale
Chicken, rice, and wheat products can be part of a balanced diet, but they do not specifically target the prevention of colon and rectal cancers. A diet rich in whole grains, fruits, and vegetables is more beneficial.
Correct Answer is A
Explanation
Choice A rationale
The client’s presentation of chest pain radiating to the left arm, shortness of breath, and diaphoresis are classic symptoms of a myocardial infarction (heart attack)56. Morphine is often administered in this situation to relieve pain and reduce the workload of the heart.
Choice B rationale
Oxycodone is a strong opioid medication used to treat severe pain. However, it is not typically the first choice for pain relief in the setting of a suspected heart attack.
Choice C rationale
Hydromorphone is another strong opioid medication used to treat severe pain. Like oxycodone, it is not typically the first choice for pain relief in the setting of a suspected heart attack.
Choice D rationale
Fentanyl is a potent opioid pain reliever. While it can be used in the management of severe pain, it is not typically the first choice for pain relief in the setting of a suspected heart attack.
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