Nokea
A healthcare professional reviewing a client's health care record notes documentation that the client has Heberden nodes of the distal interphalangeal joints. Which disorder does the healthcare professional determine that the client has?
- A. Scoliosis
- B. Osteoarthritis
- C. Rotator cuff lesions
- D. Carpal tunnel syndrome
Correct Answer: B
Rationale: The correct answer is Osteoarthritis. Osteoarthritis is characterized by hard, nontender nodules of 2 to 3 mm or larger. These osteophytes (bony overgrowths) of the distal interphalangeal joints are called Heberden nodes. In this disorder, when these nodes occur on the proximal interphalangeal joints, they are called Bouchard nodes. Heberden nodes are not associated with scoliosis, rotator cuff lesions, or carpal tunnel syndrome. Therefore, choices A, C, and D are incorrect.
You may also like to solve these questions
An LPN is taking care of an elderly client who experiences the effects of Sundowner's Syndrome almost every evening. Which of these interventions implemented by the nurse would be the most helpful?
- A. Place a nightlight in the client's room.
- B. Administer the PRN sedative prescribed by the attending physician.
- C. Remind the client that the things and people they are seeing are not real and that they are safe.
- D. Turn on the TV or radio to a station the client enjoys.
Correct Answer: A
Rationale: A nightlight will help reorient the client to his or her surroundings in the evening and nighttime hours. It is best not to challenge the reality of a client experiencing Sundowner's Syndrome, and sedatives may make the effects of the syndrome worse. Every effort should be made to keep the client's room calm, quiet, and peaceful, so noise should be kept to a minimum. Reminding the client that what they are experiencing is not real may cause distress and confusion, while turning on the TV or radio may add unnecessary stimulation instead of promoting a soothing environment.
A nurse is preparing to test cranial nerve I. Which item does the nurse obtain to test this nerve?
- A. Coffee
- B. A tuning fork
- C. A wisp of cotton
- D. An ophthalmoscope
Correct Answer: C
Rationale: To assess the function of cranial nerve I (olfactory nerve), the nurse uses a wisp of cotton to test the sense of smell in a client who reports loss of smell. The nurse assesses the patency of the client's nostrils by occluding one nostril at a time and asking the client to sniff. Next, with the client's eyes closed, the nurse occludes one nostril and presents a non-noxious aromatic substance such as coffee, toothpaste, orange, vanilla, soap, or peppermint. Choice A, 'Coffee,' is incorrect because it is used to present non-noxious aromatic substances to assess cranial nerve I. Choice B, 'A tuning fork,' is used to assess the function of cranial nerve VIII (acoustic nerve). Choice D, 'An ophthalmoscope,' is used to assess the internal structures of the eye, not cranial nerve I.
A nurse is reviewing the findings of a physical examination documented in a client's record. Which piece of information does the nurse recognize as objective data?
- A. The client is allergic to strawberries
- B. The last menstrual period was 30 days ago
- C. The client takes acetaminophen (Tylenol) for headaches
- D. A 1-2-inch scar is present on the lower right portion of the abdomen
Correct Answer: D
Rationale: Objective data in a physical examination are findings that the healthcare provider observes or measures directly. In this case, a 1 × 2-inch scar present on the lower right portion of the abdomen is a physical observation. Subjective data are based on what the client reports, such as allergies (Choice A), the date of the last menstrual period (Choice B), and self-reported medication use for headaches (Choice C). While these pieces of information are important for assessing the client's health, they are considered subjective data because they rely on the client's self-report rather than direct observation by the healthcare provider.
Around what age do children typically start to develop 'stranger anxiety'?
- A. 9 months
- B. 6 months
- C. 3 months
- D. 12 months
Correct Answer: B
Rationale: The correct answer is '6 months.' At around this age, children typically start to develop 'stranger anxiety' as they become more aware of unfamiliar faces and may start showing signs of distress or anxiety around strangers. At 3 months, infants are still very young and unlikely to display stranger anxiety. While by 9 or 12 months, children have usually already developed some level of stranger anxiety, it typically starts around 6 months, making it the most appropriate answer in this context.
The client is assessing a client who has recently found out she is pregnant. Which of the following statements would be a priority for the nurse to follow up on?
- A. "I am nervous about how painful labor will be."?
- B. "I need to review my finances and make sure I am prepared to care for a child."?
- C. "I hate this nausea that I've been having for a week."?
- D. "I am preparing myself to do this on my own because I do not have any family nearby. But I have always been very independent."?
Correct Answer: D
Rationale: The nurse should follow up on the client's lack of a support system. Even if there is no family in the area, there are supportive resources in the community that may help the client through the pregnancy and into motherhood. It is normal for the client to worry about labor, address financial concerns, and express displeasure from early pregnancy symptoms such as nausea. However, the priority is to address the client's statement about preparing to handle the pregnancy on her own due to the absence of nearby family support. This could have significant implications for the client's emotional well-being and ability to cope effectively throughout the pregnancy journey.