During a health assessment, the client reports being treated for osteoarthritis. The nurse examines the client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

Distal interphalangeal joint nodules that deviate.

Proximal intertarsal joint swelling of big toe.

Frozen, non-movable phalangeal joints.

Non-painful enlarged interphalangeal joints.

Answer and Explanation

The Correct Answer is D

A. Distal interphalangeal joint nodules that deviate: While Heberden's nodes can cause some stiffness or limited movement, "deviate" implies a significant bend or dislocation, which is not a typical characteristic of Heberden's nodes.

B. Proximal intertarsal joint swelling of big toe: This describes a swollen joint at the base of the big toe (likely gout) and is not related to Heberden's nodes, which affect the fingers.

C. Frozen, non-movable phalangeal joints: Heberden's nodes do not cause joints to become frozen or immobile. This description more accurately fits conditions like severe arthritis or advanced stages of rheumatoid arthritis where joint mobility can be significantly impaired

D. Non-painful enlarged distal interphalangeal (DIP) joints: This accurately describes Heberden's nodes, which are bony growths that typically occur on the DIP joints (closest to the fingertip) and are often painless in the early stages

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Correct Answer is C

Explanation

A. Urinary frequency: Urinary frequency is common during pregnancy due to increased pressure on the bladder from the growing uterus. However, it is not directly related to fundal height assessment.

B. Lightening: Lightening is the descent of the baby's head into the pelvis, which typically occurs in the third trimester, not at 15 weeks.

C. Fetal movement: Fetal Movement is an appropriate choice because it directly relates to determining the presence of a viable fetus. This information can assist in ruling out a complete molar pregnancy, where no fetal movement would be expected. It can guide the nurse to investigate further, potentially leading to more specific diagnostic procedures such as an ultrasound to confirm the underlying cause of the abnormal fundal height.

D. Braxton-Hicks contractions: Braxton-Hicks contractions can occur throughout pregnancy, but they are not a cause for concern at 15 weeks.

A. Takes an oral anticoagulant. B. Works in a day care center. C. Adheres to a gluten free diet. D. Recently had dental surgery.

Correct Answer is A

Explanation

A. Takes an oral anticoagulant. Ecchymosis, or bruising, can be a side effect of anticoagulant therapy and may indicate potential bleeding issues that require further assessment.

B. Works in a day care centre. While exposure to children might increase the risk of minor injuries, it is less likely to be directly related to the ecchymosis observed.

C. Adheres to a gluten-free diet. This dietary preference is not likely to be directly related to the ecchymosis observed.

D. Recently had dental surgery. While recent surgery might be relevant, it is less likely to cause widespread ecchymosis unless there were complications.

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During a health assessment, the client reports being treated for osteoarthritis. The nurse examines the client's hands and finds Heberden's nodes. Which finding should the nurse document in the client's medical record?

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Naxlex Comprehensive Predictor Exams

In assessing a primigravida woman at 15 weeks gestation by dates, the nurse palpates the fundus at the umbilicus. Based on this assessment finding, it is most important for the nurse to obtain information about the occurrence of which condition?

Correct Answer is C

Explanation

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

Correct Answer is A

Explanation

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