A patient who has had rheumatoid arthritis (RA) for years comes to the clinic to ask about changes in her hands. Which changes are associated with chronic RA?

A. Stuporous: Stupor is a state of near-unconsciousness where the patient only responds to vigorous or noxious stimuli. A stuporous patient would likely achieve a Glasgow Coma Score (GCS) higher than 3 due to minimal motor or eye-opening responses. It represents a slightly higher level of arousal than coma.

B. Obtunded: This state involves reduced alertness and a slowed psychomotor response to the environment. An obtunded patient typically responds to light touch or a loud voice, which would result in a mid-range GCS score. It does not reflect the total lack of responsiveness associated with a score of 3.

C. Lethargic: Lethargy describes a patient who is drowsy but easily aroused by name or normal conversation. Such a patient would open their eyes spontaneously and be oriented, resulting in a GCS score near the maximum of 15. It is a mild impairment of consciousness compared to the other choices.

D. Comatose: A Glasgow Coma Score of 3 is the lowest possible rating, indicating no eye opening, no verbal response, and no motor response to any stimuli. This objective value defines a state of deep unconsciousness or coma. Documentation must reflect this total absence of neurological arousal and response.

D. Handwashing: This is the initial step to ensure infection control and prevent the transmission of nosocomial pathogens. It must precede any physical contact with the patient's integument or environment. Maintaining aseptic technique is fundamental to all nursing physical examination protocols.

C. Inspecting for position: Inspection provides visual data on patient distress or abdominal contour without disturbing the viscera. This non-invasive step allows the nurse to observe for signs of peritonitis, such as lying perfectly still. It must be performed before any manual manipulation of the abdomen.

F. Auscultating for bowel sounds: Auscultation follows inspection to ensure that bowel sounds are not artificially altered by manual manipulation or palpation. This sequence prevents the elicitation of false hyperactive or hypoactive sounds. It provides a baseline for peristaltic activity before the abdomen is touched.

E. Palpating lightly: Light palpation identifies areas of muscular guarding and superficial masses while minimizing patient discomfort. This step precedes deep palpation to prevent premature elicitation of severe pain. It helps localize the area of maximal tenderness mentioned in the clinical presentation.

B. Palpating for rebound tenderness: Deep palpation for rebound tenderness is performed last because it often causes significant pain and distress. This is a specific assessment for peritoneal irritation often seen in clinical cases of appendicitis. It provides the final physical evidence of an acute abdominal process.

A. Notifying the health care provider: Communication of findings to the physician is the final step after a comprehensive assessment is documented. This allows the nurse to provide a complete clinical picture, including vital signs and specific abdominal findings. Timely reporting facilitates urgent surgical or medical intervention.