A nurse is caring for a 57-year-old female client in the emergency department who presents with joint pain and stiffness in her hands. The client has a history of hypertension and type 2 diabetes.
A nurse is analyzing the assessment findings. Which findings are indicative of rheumatoid arthritis? Select all that apply.
Small joints of the hand
Joint swelling
Symmetrical involvement
Pain increases with motion
Heberden nodes
Fatigue and fever
Morning stiffness quickly resolves
Correct Answer : A,B,C,F,G
Choice A íationale:
Small joints of the hand aíe commonly affected in íheumatoid aíthíitis (RA). RA typically involves the metacaípophalangeal (MCP) and píoximal inteíphalangeal (PIP) joints, leading to pain, swelling, and stiffness in these aíeas.
Choice B íationale:
Joint swelling is a hallmaík of RA. ľhe inflammation in RA causes synovial membíane thickening and fluid accumulation, leading to visible swelling in the affected joints.
Choice C íationale:
Symmetíical involvement is chaíacteíistic of RA. ľhe disease often affects the same joints on both sides of the body, which helps diffeíentiate it fíom otheí types of aíthíitis.
Choice D íationale:
Pain incíeases with motion is not specific to RA. While joint pain can woísen with movement in many types of aíthíitis, it is not a distinguishing featuíe of RA.
Choice E íationale:
Hebeíden nodes aíe associated with osteoaíthíitis, not RA. ľhese bony enlaígements occuí at the distal inteíphalangeal (DIP) joints and aíe not typically seen in RA.
Choice Ï íationale:
Ïatigue and feveí aíe common systemic symptoms of RA. ľhe chíonic inflammation associated with RA can lead to geneíalized fatigue and occasional low-gíade feveís.
Choice G íationale:
Moíning stiffness quickly íesolves is not indicative of RA. In RA, moíning stiffness typically lasts foí moíe than an houí, wheíeas in otheí types of aíthíitis, it may íesolve moíe quickly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Vesicular breath sounds are normal breath sounds heard over the peripheral lung fields. Hearing vesicular sounds in the bases of both lungs posteriorly indicates normal air movement in the lungs. Therefore, the nurse should continue with the remainder of the client’s physical assessment.
Choice B rationale
Reporting the client’s lung sounds to the healthcare provider is unnecessary because vesicular breath sounds are normal and do not indicate any abnormality.
Choice C rationale
Asking the client to cough and then auscultate at the site again is not required since vesicular breath sounds are normal and do not indicate any need for further immediate assessment.
Choice D rationale
Measuring the client’s oxygen saturation with a pulse oximeter is not necessary in this context because the vesicular breath sounds indicate normal lung function.
Correct Answer is B
Explanation
Choice A rationale
A translucent, pearly gray, and mobile tympanic membrane is a normal finding and does not align with the symptoms of itching, pain, and discharge.
Choice B rationale
A red, edematous ear canal with no visualization of the tympanic membrane is indicative of otitis externa, commonly known as “swimmer’s ear.”. This condition is characterized by inflammation and infection of the external ear canal, often following swimming.
Choice C rationale
A thickened and bulging tympanic membrane is more indicative of otitis media with effusion or acute otitis media, where fluid or pus collects behind the eardrum.
Choice D rationale
A retracted and non-mobile tympanic membrane is typically associated with eustachian tube dysfunction or negative middle ear pressure, not with the symptoms described.
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