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A nurse is caring for a 57-year-old female client in the emergency department who presents with joint pain and stiffness in her hands. The client has a history of hypertension and type 2 diabetes.

 

Exhibits

 

Nurses’ Notes (0700hrs):

 

  • The client reports experiencing joint pain and stiffness in her hands for the past few months.
  • The pain is described as aching and is worse in the morning, lasting for about an hour before improving.
  • The client mentions difficulty in performing daily tasks such as buttoning clothes and opening jars.
  • There is visible swelling in the small joints of both hands.
  • The client denies any recent trauma or injury to the hands.
  • The client reports feeling fatigued and has had occasional low-grade fevers.
  • The client is currently taking medication for hypertension and diabetes.

 

Medical History:

 

  • Hypertension for 10 years, managed with medication.
  • Type 2 diabetes for 5 years, managed with oral hypoglycemic agents.
  • No known allergies.
  • Family history of autoimmune diseases.

 

Vital Signs (0700hrs):

 

  • Temperature: 37.8°C (100°F)
  • Blood Pressure: 140/90 mmHg
  • Heart Rate: 82 bpm
  • Respiratory Rate: 18 breaths per minute
  • Oxygen Saturation: 98% on room air

 

Physical Examination Results (0700hrs):

 

  • Swelling and tenderness in the metacarpophalangeal and proximal interphalangeal joints of both hands.
  • Limited range of motion in the affected joints.
  • No deformities observed.
  • Skin over the joints appears slightly erythematous.
  • No signs of infection or injury.

 

Diagnostic Results (0700hrs):

 

  • Complete Blood Count (CBC): WBC 8,000/mm³ (4,000-11,000/mm³), Hemoglobin 13.5 g/dL (12-16 g/dL), Platelets 250,000/mm³ (150,000-450,000/mm³)
  • Erythrocyte Sedimentation Rate (ESR): 40 mm/hr (0-20 mm/hr)
  • C-Reactive Protein (CRP): 15 mg/L (0-10 mg/L)
  • Rheumatoid Factor (RF): Positive

 

A nurse is analyzing the assessment findings. Which findings are indicative of rheumatoid arthritis? Select all that apply.

A.

Small joints of the hand

B.

Joint swelling

C.

Symmetrical involvement

D.

Pain increases with motion

E.

Heberden nodes

F.

Fatigue and fever

G.

Morning stiffness quickly resolves

Question Solution

Correct Answer : A,B,C,F,G

Choice A rationale: Small joints of the hand are commonly affected in rheumatoid arthritis (RA). RA typically involves the metacarpophalangeal (MCP) and proximal interphalangeal (PIP) joints, leading to pain, swelling, and stiffness in these areas.

 

Choice B rationale: Joint swelling is a hallmark of RA. The inflammation in RA causes synovial membrane thickening and fluid accumulation, leading to visible swelling in the affected joints.

 

Choice C rationale: Symmetrical involvement is characteristic of RA. The disease often affects the same joints on both sides of the body, which helps differentiate it from other types of arthritis.

 

Choice D rationale: Pain increases with motion is not specific to RA. While joint pain can worsen with movement in many types of arthritis, it is not a distinguishing feature of RA.

 

Choice E rationale: Heberden nodes are associated with osteoarthritis, not RA. These bony enlargements occur at the distal interphalangeal (DIP) joints and are not typically seen in RA.

 

Choice F rationale: Fatigue and fever are common systemic symptoms of RA. The chronic inflammation associated with RA can lead to generalized fatigue and occasional low-grade fevers.

 

Choice G rationale: Morning stiffness quickly resolves is not indicative of RA. In RA, morning stiffness typically lasts for more than an hour, whereas in other types of arthritis, it may resolve more quickly

 


View Related questions

Correct Answer is C

Explanation

Choice A rationale

Documenting the presence of borborygmi is appropriate, but it does not address the need for a thorough assessment of all quadrants. Borborygmi are loud, high-pitched, almost continuous gurgling sounds that indicate hyperactive bowel sounds.

Choice B rationale

Auscultating the remaining quadrants is necessary to complete the assessment and ensure that the findings are consistent throughout the abdomen. This step helps to identify any variations in bowel sounds that may indicate different underlying conditions.

Choice C rationale

Elevating the head of the client’s bed immediately is not indicated in this situation. The primary focus should be on completing the assessment of bowel sounds in all quadrants.

Choice D rationale

Using the bell of the stethoscope to auscultate again is not necessary, as the diaphragm is the appropriate part of the stethoscope to use for assessing bowel sounds. The diaphragm is better suited for picking up high-pitched sounds like borborygmi.

Correct Answer is A

Explanation

Choice A rationale: Administering oxygen via nasal cannula is the first priority in this scenario. The client’s oxygen saturation is 88% on room air, which indicates hypoxemia. Providing supplemental oxygen will help improve the client’s oxygenation and alleviate symptoms of shortness of breath. Ensuring adequate oxygenation is crucial to prevent further respiratory distress and potential complications.

Choice B rationale: Obtaining a sputum culture is important to identify the causative organism of the client’s respiratory infection and guide appropriate antibiotic therapy. However, this action is not the immediate priority. Addressing the client’s hypoxemia by administering oxygen takes precedence to stabilize the client’s condition.

Choice C rationale: Administering an antipyretic medication can help reduce the client’s fever and improve comfort. However, this is not the immediate priority. The client’s hypoxemia and respiratory distress need to be addressed first by administering oxygen.

Choice D rationale: Encouraging the client to increase fluid intake is important for maintaining hydration and helping to thin respiratory secretions. However, this action is not the immediate priority. The client’s hypoxemia and respiratory distress need to be addressed first by administering oxygen