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.
Small joints of the hand
Joint swelling
Symmetrical involvement
Pain increases with motion
Heberden nodes
Fatigue and fever
Morning stiffness quickly resolves
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
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Correct Answer is B
Explanation
Choice A rationale
A translucent, pearly gray, and mobile tympanic membrane is a normal finding and does not align with the symptoms of itching, pain, and discharge.
Choice B rationale
A red, edematous ear canal with no visualization of the tympanic membrane is indicative of otitis externa, commonly known as “swimmer’s ear.”. This condition is characterized by inflammation and infection of the external ear canal, often following swimming.
Choice C rationale
A thickened and bulging tympanic membrane is more indicative of otitis media with effusion or acute otitis media, where fluid or pus collects behind the eardrum.
Choice D rationale
A retracted and non-mobile tympanic membrane is typically associated with eustachian tube dysfunction or negative middle ear pressure, not with the symptoms described.
Correct Answer is D
Explanation
Choice A rationale
While jugular vein distention can indicate fluid overload or heart failure, it is not a direct assessment of orthopnea, which is the difficulty breathing while lying flat.
Choice B rationale
Auscultating breath sounds while the client is supine can provide information about lung function and the presence of abnormal breath sounds, but it does not specifically address orthopnea.
Choice C rationale
Measuring the blood pressure when the client is lying and standing assesses for orthostatic hypotension, which is a drop in blood pressure upon standing. While orthostatic hypotension can contribute to symptoms of dizziness or fainting upon assuming an upright position, it does not directly assess orthopnea.
Choice D rationale
Orthopnea is a condition where individuals have difficulty breathing while lying flat and may need to sleep with multiple pillows or in a more upright position to alleviate symptoms.Therefore, asking the client about the number of pillows used for sleep can provide valuable information about the presence and severity of orthopnea.