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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Free Nursing Study Resources

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

Explanation

Choice A rationale

Providing diversionary activities for the client can help distract them and reduce the likelihood of them pulling on their NG tube. Diversionary activities can include engaging the client in conversation, providing them with puzzles or games, or allowing them to watch television or listen to music. These activities can help occupy the client’s time and attention, reducing the need for restraints.

Choice B rationale

Assisting the client with toileting at frequent intervals can address any discomfort or need that may be causing the client to pull on their NG tube. Ensuring that the client is comfortable and their needs are met can reduce agitation and the likelihood of them pulling on the tube.

Choice C rationale

Involving the family in the client’s care can provide additional support and reassurance to the client. Family members can help calm the client and provide a familiar presence, which can reduce anxiety and the need for restraints.

Choice E rationale

Using an electronic bed alarm device can alert the nursing staff if the client attempts to get out of bed or pull on their NG tube. This allows for timely intervention without the need for physical restraints.

A. Dextrose 5% in water. B. 0.45% sodium chloride. C. Dextrose 5% in 0.9% sodium chloride. D. Lactated Ringers.

Correct Answer is D

Explanation

Choice A rationale

Dextrose 5% in water is not recommended for initial fluid resuscitation in burn patients because it does not provide the necessary electrolytes to address the fluid shifts and electrolyte imbalances that occur after a burn injury.

Choice B rationale

0.45% sodium chloride is a hypotonic solution and is not suitable for initial fluid resuscitation in burn patients. It can lead to cellular swelling and does not adequately replace the lost extracellular fluid.

Choice C rationale

Dextrose 5% in 0.9% sodium chloride is not the preferred choice for initial fluid resuscitation in burn patients. While it provides both glucose and electrolytes, it is not as effective as Lactated Ringers in addressing the specific needs of burn patients.

Choice D rationale

Lactated Ringers is the recommended fluid for initial resuscitation in burn patients. It is an isotonic solution that helps to restore circulating volume, correct electrolyte imbalances, and prevent hypovolemic shock.

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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 caring for a client who is cognitively impaired and repeatedly pulls on his NG tube. Which of the following actions should the nurse take before requesting a prescription for restraints? (Select all that apply.)

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

Explanation

A nurse is monitoring the fluid replacement of a client who has sustained burns. The nurse should administer which of the following fluids in the first 24 hours following a burn injury?

Correct Answer is D

Explanation

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