Exhibits
Which information from the history and physical, nurses' note, and flow sheet requires further evaluation? Select all that apply.
Occupation of legal secretary
Stiffness in hands for 3 months
Radial and pedal pulses 2+
Pain in bilateral hands and wrists
History of asthma using albuterol inhaler PRN
Capillary refill 2 seconds
Body mass index (BMI) of 31 kg/m2
Client's hobbies
Correct Answer : A,B,D,G,H
A. Occupation of legal secretary: The client works as a legal secretary, which may involve extensive typing or repetitive hand movements. This can contribute to musculoskeletal stress or strain, potentially exacerbating symptoms like pain and stiffness in the hands.
B. Stiffness in hands for 3 months: The client reports stiffness in both hands and wrists for the past 3 months, which could suggest an inflammatory arthritis such as rheumatoid arthritis (RA). This warrants further evaluation, especially given her family history of arthritis.
C. Radial and pedal pulses 2+: A rating of 2+ for radial and pedal pulses is normal, indicating no circulation issues, and does not need further evaluation.
D. Pain in bilateral hands and wrists: Persistent, symmetrical pain in the hands and wrists, particularly with palpation, may indicate a condition like rheumatoid arthritis. This symptom, in combination with morning stiffness, needs further investigation.
E. History of asthma using albuterol inhaler PRN: The client's history of well-controlled asthma, managed with an albuterol inhaler as needed for exacerbations, does not directly relate to her current presentation of hand pain and stiffness.
F. Capillary refill 2 seconds: A capillary refill time of 2 seconds is within the normal range, indicating adequate peripheral perfusion. This finding suggests that there are no immediate circulatory issues contributing to her hand pain and stiffness and does not require further evaluation.
G. Body mass index (BMI) of 31 kg/m²: A BMI of 31 falls within the obese range, which can increase the risk for musculoskeletal issues and other chronic conditions. This factor should be evaluated further, as obesity may affect joint health.
H. Client's hobbies: The client enjoys hobbies like gardening and crocheting, which involve repetitive hand movements. These activities could exacerbate the pain and stiffness in her hands, making it important to evaluate whether these hobbies are contributing to her symptoms.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","C"]
Explanation
A. Contagious until symptoms subside: Streptococcal pharyngitis is contagious until 24 hours after starting antibiotics, not until all symptoms are gone. This is important for limiting transmission to others in the household or school setting.
B. Sandpaper-like rash: A sandpaper-textured rash is a hallmark sign of scarlet fever, which is a complication of strep throat. It usually begins on the neck or chest and spreads, often feeling coarse to the touch.
C. Peeling and flaking skin in a week: Desquamation, or skin peeling, is common several days after a strep rash subsides, particularly on the hands and feet. This symptom signals the healing phase of scarlet fever.
D. Darkening of skin under arms: Darkened underarm skin is typically linked to acanthosis nigricans, associated with insulin resistance or obesity. It is not seen with streptococcal infections or fever-related conditions.
E. Fever lasting for 7 to 10 days: Fever from strep throat usually resolves quickly within 24–48 hours of initiating antibiotic therapy. Prolonged fever would be atypical and requires further evaluation for complications.
Correct Answer is D
Explanation
A. Avoid forcing apart the teeth: Placing objects in the client’s mouth or trying to pry open the teeth can cause injury. It is important to let the seizure pass without interfering with the jaw or mouth.
B. Loosen clothing around the neck: Loosening tight clothing reduces the risk of airway obstruction or restricted breathing during a seizure. This is a correct and helpful intervention.
C. Position the head from injury: Protecting the client’s head with a soft object prevents trauma during convulsions. This is a recommended and safe practice during seizures.
D. Secure the limbs to the body: Restraining or holding down limbs can cause musculoskeletal injuries and increase agitation. Seizure safety protocols emphasize allowing movement without physical restraint.
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