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 A

Explanation

A. Inspection. Papilledema, swelling of the optic disc due to increased intracranial pressure, is primarily assessed through inspection of the optic disc using an ophthalmoscope. The nurse would look for optic disc swelling and blurred disc margins.

B. Auscultation. Auscultation is not appropriate for assessing papilledema, as it involves listening for sounds such as heart, lung, or bowel sounds.

C. Palpation. Palpation is not appropriate for assessing papilledema, as it involves touching and feeling for abnormalities, which would not be possible with the optic disc.

D. Percussion. Percussion is not appropriate for assessing papilledema, as it involves tapping the body surface to elicit sounds or vibrations, which would not provide information about the optic disc.

A. Tell the client the medication needs more time to work. B. Reassess the client and the level of pain. C. Ask the unlicensed assistive personnel (UAP) to offer a backrub to the client. D. Encourage the client to focus on taking deep breaths.

Correct Answer is B

Explanation

A. Telling the client the medication needs more time: While true for some medications, it's important to assess the severity of the pain to determine if further action is needed.

B. Reassessing the client's pain: This is the most crucial step. Reassessment helps determine the effectiveness of the medication and identify any potential issues.

C. Asking UAP to offer a backrub: While comfort measures can be helpful, delegation to an UAP should only occur after a nurse assessment and with clear instructions. In this case, pain management is the priority.

D. Encouraging deep breaths: Distraction techniques can be a complementary approach, but reassessing the pain level is the most urgent step.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which assessment technique should the nurse use to confirm the presence of papilledema in a client with a rapidly decreasing level of consciousness?

Correct Answer is A

Explanation

A client is complaining of severe pain after being medicated one hour ago with hydrocodone with acetaminophen one tablet orally. Which intervention should the nurse implement next?

Correct Answer is B

Explanation

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