While assessing a patient with degenerative joint disease, the nurse notices Heberden’s nodes, and large prominences on the patient’s fingers that are reddened and painful.

What should the nurse do?

Discuss strategies for managing chronic pain with the patient.

Check the patient’s radial pulses and capillary refill time.

Immediately notify the healthcare provider of the finding.

Review the patient’s dietary intake of high-protein foods.

Answer and Explanation

The Correct Answer is A

Choice A rationale
Heberden’s nodes are bony swellings that develop at the end joints (distal interphalangeal joints) of fingers, particularly the fingers closest to the nails. They are a characteristic feature of osteoarthritis, a degenerative joint disease. Osteoarthritis causes the protective cartilage in the joints to wear down over time, leading to the development of these bony growths, which can be painful and limit joint movement. Therefore, discussing strategies for managing chronic pain with the patient is the most appropriate action for the nurse to take.
Choice B rationale
While checking the patient’s radial pulses and capillary refill time is a part of a comprehensive physical assessment, it is not directly related to the management of Heberden’s nodes or osteoarthritis.
Choice C rationale
Although Heberden’s nodes are a sign of osteoarthritis, they are not typically an emergency that requires immediate notification of the healthcare provider. They are a common finding in individuals with osteoarthritis and are usually managed with conservative measures such as pain management and physical therapy.
Choice D rationale
Reviewing the patient’s dietary intake of high-protein foods is not directly related to the management of Heberden’s nodes or osteoarthritis. While a balanced diet is important for overall health, it does not specifically address the pain and limited joint movement associated with Heberden’s nodes.

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Correct Answer is A

Explanation

Lower back pain and hypotension are symptoms of an ABO incompatibility reaction, which is a serious complication of blood transfusion. This reaction occurs when the client receives a blood type that is incompatible with their own. It can cause a rapid and severe response, including back pain, hypotension, fever, and chills. This should be reported immediately to the healthcare provider.

A. Cold and dry skin. B. Facial puffiness and periorbital edema. C. Hematocrit of 30% (0.30 volume fraction). D. Further decline in the level of consciousness.

Correct Answer is D

Explanation

Choice A rationale
Cold and dry skin can be a symptom of hypothyroidism, but it’s not typically a sign that requires immediate action.
Choice B rationale
Facial puffiness and periorbital edema can be symptoms of hypothyroidism, but they’re not typically signs that require immediate action.
Choice C rationale
A hematocrit of 30% (0.30 volume fraction) is lower than the normal range, indicating anemia. While this is a concern and should be addressed, it’s not typically a sign that requires immediate action in the context of hypothyroidism.
Choice D rationale
A further decline in the level of consciousness can be a serious sign of deteriorating health in a client with hypothyroidism and should be acted upon immediately.

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While assessing a patient with degenerative joint disease, the nurse notices Heberden’s nodes, and large prominences on the patient’s fingers that are reddened and painful. What should the nurse do?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client experiences an ABO incompatibility reaction after multiple blood transfusions. Which finding should the nurse report immediately to the healthcare provider?

Correct Answer is A

Explanation

A client with a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding should the nurse act upon immediately?

Correct Answer is D

Explanation

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While assessing a patient with degenerative joint disease, the nurse notices Heberden’s nodes, and large prominences on the patient’s fingers that are reddened and painful.

What should the nurse do?