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When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?

Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?

An older male client reports to the nurse that his feet are cold. Before covering the client’s feet, which assessment(s) should the nurse complete? Select all that apply.

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which querry should the nurse ask first?

While observing a client’s face, which assessment finding requires immediate intervention by the nurse?

A client presents with itching and pain in the left ear that started several days after beginning swim lessons. The nurse observes a discharge coming from the ear with a musty odor.

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.

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

During an abdominal assessment, a client with a temperature of 103°F (39.4°C) experiences pain and abruptly stops inhaling during deep palpation. Which prescription is most important for the nurse to implement?