A nurse is completing a physical assessment of a client who has early osteoarthritis. Which of the following manifestations should the nurse expect?
Ulnar deviation
Symmetric joints affected
Pain worsens with activity
Weight loss
The Correct Answer is C
Choice A reason: Ulnar Deviation
Ulnar deviation, or the bending of the fingers towards the ulna (the outer bone of the forearm), is more commonly associated with rheumatoid arthritis rather than osteoarthritis. Rheumatoid arthritis typically affects the joints symmetrically and can lead to deformities such as ulnar deviation due to chronic inflammation.
Choice B reason: Symmetric Joints Affected
Symmetric joint involvement is characteristic of rheumatoid arthritis, not osteoarthritis. Osteoarthritis usually affects joints asymmetrically, meaning it can affect one joint more than the other. It commonly affects weight-bearing joints such as the knees, hips, and spine.
Choice C reason: Pain Worsens with Activity
Pain that worsens with activity is a hallmark symptom of osteoarthritis. This condition is caused by the breakdown of cartilage in the joints, leading to pain and stiffness, especially after physical activity. The pain typically improves with rest but can become more persistent as the disease progresses.
Choice D reason: Weight Loss
Weight loss is not a typical manifestation of osteoarthritis. In fact, being overweight or obese is a risk factor for developing osteoarthritis, particularly in weight-bearing joints. Weight management is often recommended to help reduce the stress on affected joints and alleviate symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason:
Turn the client every 4 hours: Regularly turning the client can help prevent pressure ulcers and improve overall circulation, but it is not the most effective measure specifically for preventing ventilator-associated pneumonia (VAP). While repositioning can help with lung expansion and secretion clearance, oral care is more directly related to reducing VAP risk.
Choice B reason:
Brush the client’s teeth with a suction toothbrush every 12 hours: Oral care is crucial in preventing VAP. Bacteria from the mouth can easily travel to the lungs, especially in intubated patients. Using a suction toothbrush helps remove dental plaque and secretions, reducing the bacterial load and the risk of infection. This practice is a key component of VAP prevention bundles.
Choice C reason:
Provide humidity by maintaining moisture within the ventilator tubing: While maintaining humidity is important to prevent drying of the respiratory mucosa and to help with secretion clearance, it does not directly reduce the risk of VAP. Proper humidification is necessary for patient comfort and respiratory function but is not a primary VAP prevention strategy.
Choice D reason:
Position the head of the client’s bed in the flat position: Positioning the head of the bed flat can increase the risk of aspiration, which is a significant risk factor for VAP. The head of the bed should be elevated to 30-45 degrees to reduce the risk of aspiration and promote better lung expansion.
Correct Answer is C
Explanation
Choice A reason:
Promoting oral hygiene is important for preventing infection and maintaining overall health, especially after surgery involving the mouth. However, it is not the immediate priority in the postoperative period.
Choice B reason:
Ensuring adequate nutrition is crucial for healing and recovery, but it is not the most urgent concern immediately after surgery. Nutritional needs can be addressed once the client is stable and the risk of complications has been minimized.
Choice C reason:
Preventing aspiration is the priority action. After surgery for a fractured mandible with intermaxillary fixation, the client is at high risk for aspiration due to the inability to open the mouth and clear secretions effectively. Aspiration can lead to serious complications such as pneumonia, making it the most critical concern.
Choice D reason:
Relieving the client’s pain is important for comfort and recovery, but it is not the highest priority immediately after surgery. Pain management should be addressed once the client’s airway and breathing are secure.
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