A nurse is assessing a client newly diagnosed with early-onset osteoarthritis. Which manifestation should the nurse expect?
Ulnar deviation.
Symmetric joints are affected.
Weight loss.
Joint stiffness and limited range of motion.
The Correct Answer is D
Choice A reason:
Ulnar deviation, which is the angling of the fingers towards the little finger side of the hand, is more commonly associated with rheumatoid arthritis, not osteoarthritis. Osteoarthritis typically affects the joint's cartilage, leading to pain and stiffness, rather than causing the fingers to deviate.
Choice B reason:
Symmetric joint involvement is also more characteristic of rheumatoid arthritis. Osteoarthritis usually affects joints asymmetrically, meaning it's more likely to affect one side of the body or one particular joint at a time.
Choice C reason:
Weight loss is not a direct manifestation of osteoarthritis. In fact, being overweight is a risk factor for developing osteoarthritis due to the increased stress on weight-bearing joints. However, weight management through diet and exercise can be part of the treatment plan for osteoarthritis to alleviate symptoms and improve joint function.
Choice D reason:
Joint stiffness and limited range of motion are hallmark manifestations of osteoarthritis. These symptoms result from the breakdown of cartilage within the joints, which leads to pain and difficulty moving the affected joint. Stiffness is often most noticeable upon waking or after periods of inactivity, and the range of motion may decrease as the condition progresses.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A Reason
Performing a bladder scan can help determine the volume of urine in the bladder and assess for urinary retention, which could contribute to bladder spasms. However, this is not typically the first intervention. The priority is to ensure that the catheter is patent and draining correctly, as blockages can cause immediate discomfort and increased spasms
Choice B Reason
Stopping the irrigation could be considered if there is a concern that the CBI is contributing to the spasms. However, this would not be the first action taken. It is essential first to assess the catheter's patency and the flow of the irrigation to rule out any obstruction or kinking causing the spasms.
Choice C Reason
Administering an oral analgesic may help alleviate the discomfort caused by bladder spasms, but it does not address the underlying cause. Pain relief is important, but the initial step should be to check for and resolve any mechanical issues with the catheter system that could be causing the spasms.
Choice D Reason
Ensuring that the catheter is draining properly is the first and most crucial intervention. If the catheter is blocked or kinked, it can cause bladder distention and increased spasms. Checking the catheter's patency and the flow of irrigation can quickly resolve the issue and provide relief to the patient. If the catheter is found to be obstructed, resolving the blockage can decrease the severity of the spasms and improve the patient's comfort.
Correct Answer is B
Explanation
Choice A Reason
A blood pressure of 120/80 mmHg is considered within the normal range and is an ideal target for most individuals being treated for hypertension. This finding would not typically alert the nurse to a side effect of lisinopril.
Choice B Reason
Serum potassium of 5.5 mEq/L is higher than the normal range, which is typically between 3.5 and 5.0 mEq/L. Lisinopril can cause hyperkalemia, which is an elevated level of potassium in the blood. This is a known side effect of lisinopril, especially in clients with renal impairment, as it inhibits the renin-angiotensin-aldosterone system and reduces potassium excretion.
Choice C Reason
A heart rate of 80 beats per minute is within the normal range for adults, which is typically 60-100 beats per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.
Choice D Reason
A respiration rate of 16 breaths per minute is within the normal range for adults, which is typically 12-20 breaths per minute at rest. This finding would not alert the nurse to a side effect of lisinopril.
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