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.

Exhibits

A nurse is analyzing the assessment findings. Which findings are indicative of rheumatoid arthritis? Select all that apply.

The nurse performs a two-point discrimination test by applying two sterile needles lightly to the fingertips and moving the needle tips in ever-closing distances.

A middle-aged adult client senses two points at a distance of 3 mm on the fingertips and 10 mm on the palms of the hands.

Which interpretation of this finding is accurate?

The nurse is examining a female client who states she has no complaints, so has not had a physical examination for over 5 years.

The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night.

To obtain further data regarding possible orthopnea, which action should the nurse take?

To assess a client’s pupillary reaction to accommodation, which action should the nurse take?

A nurse is caring for a 45-year-old male client in the emergency department who sustained a fall from a ladder. The client has a closed and displaced fracture of the right ulna and radius. The nurse is monitoring the client closely for any changes in condition.

A nurse is caring for a 45-year-old male client in the emergency department with a closed and displaced fracture of the right ulna and radius. Based on the exhibits provided, what is the priority nursing action at this time?

To objectively confirm the presence of fever, before taking the client’s temperature, which action should the nurse take?

While obtaining a client’s health history related to smoking cigarettes, the nurse plans to determine the client’s smoking pack years.

What information should the nurse obtain for this calculation? Select all that apply.

When evaluating a client’s rectal bleeding, which findings should the nurse document?

An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client’s skin for which finding?

While observing a client’s face, which assessment finding requires immediate intervention by the nurse?