A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?

Unilateral joint involvement.

Ulnar deviation.

Decreased sedimentation rate.

Fractures of the spine.

Answer and Explanation

The Correct Answer is B

Choice A rationale

Unilateral joint involvement is not typical of rheumatoid arthritis. This condition usually affects joints symmetrically, meaning both sides of the body are involved. Rheumatoid arthritis is an autoimmune disorder where the immune system mistakenly attacks the synovium, leading to inflammation and joint damage.

Choice B rationale

Ulnar deviation is a common finding in rheumatoid arthritis. It occurs due to chronic inflammation and damage to the joints, particularly in the hands. The fingers may deviate towards the ulnar side (the side of the little finger) due to the weakening of the ligaments and tendons.

Choice C rationale

Decreased sedimentation rate is not a typical finding in rheumatoid arthritis. In fact, the erythrocyte sedimentation rate (ESR) is usually elevated in this condition due to the ongoing inflammation. ESR is a marker of inflammation and is used to monitor disease activity.

Choice D rationale

Fractures of the spine are not a common finding in rheumatoid arthritis. While osteoporosis can be a complication of rheumatoid arthritis, leading to an increased risk of fractures, the spine is not typically the primary site of joint involvement in this condition.

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Correct Answer is C

Explanation

Choice A rationale

A respiratory rate of 18/min is within the normal range for adults and does not typically require immediate intervention.

Choice B rationale

A blood pressure of 102/66 mm Hg is within the normal range for adults and does not typically require immediate intervention.

Choice C rationale

Yellow-green drainage from a surgical incision suggests infection and should be reported to the provider immediately for further evaluation and management.

Choice D rationale

Straw-colored urine from an indwelling urinary catheter is a normal finding and indicates adequate hydration and kidney function

A. Wound infection. B. Obesity. C. Altered mental status. D. Pain medication administration. E. Poor nutritional state.

Correct Answer is ["A","B","E"]

Explanation

Wound infection is a significant risk factor for dehiscence. Infections can weaken the wound edges and delay healing, increasing the likelihood of the wound reopening.

Choice B rationale

Obesity is a risk factor for dehiscence because excess adipose tissue can place additional stress on the wound, impair blood flow, and delay healing.

Choice C rationale

Altered mental status is not directly associated with an increased risk of dehiscence. While it may affect a patient’s ability to follow postoperative care instructions, it is not a primary risk factor.

Choice D rationale

Pain medication administration is not a risk factor for dehiscence. Pain management is essential for recovery and does not contribute to wound reopening.

Choice E rationale

Poor nutritional state is a risk factor for dehiscence because adequate nutrition is essential for wound healing. Malnutrition can impair the body’s ability to repair tissues and increase the risk of wound complications.

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A nurse is assessing a client who has rheumatoid arthritis. Which of the following findings should the nurse expect?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Correct Answer is C

Explanation

A nurse is teaching a newly licensed nurse about the risk factors for dehiscence for clients who have surgical incisions. Which of the following factors should the nurse include in the teaching? (Select all that apply.)

Correct Answer is ["A","B","E"]

Explanation

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