Nokea
A nurse assesses an area of skin over a bony prominence. What finding would
be most concerning?
- A. Redness
- B. Non-blanching
- C. Blanching
- D. Warmth
Correct Answer: A
Rationale:
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The nurse is preparing to administer medications to a client with osteoarthritis.
What is the goal of medication therapy?
- A. Eradicate the disease
- B. Reduce pain and inflammation
- C. Turn on the immune system
- D. Manage weight loss
Correct Answer: B
Rationale:
The nurse is preparing communication for a provider. The client is experiencing
acute pain greater than the severity of the fracture. Distal to the injury, he is
experiencing a 'pins and needles' sensation. The pulse is weak and thready but
is bounding on all unaffected extremities. What emergent condition does the
nurse suspect?
- A. Ischial tuberosity
- B. Compartment syndrome
- C. Broken arm syndrome
- D. Pulmonary embolism
Correct Answer: B
Rationale:
Which finding is not typically associated with inflammation in a client?
- A. Pain
- B. Heat
- C. Polyuria
- D. Erythema
Correct Answer: C
Rationale: Polyuria is excessive urination and is not a typical assessment finding in inflammation. Inflammation commonly presents with pain (A), heat (B), and erythema (D) which are classic signs of an inflammatory response. Pain results from the release of inflammatory mediators, heat is due to increased blood flow, and erythema is caused by vasodilation and increased blood flow to the area. Polyuria is more likely associated with conditions such as diabetes or renal issues, rather than inflammation.
A nurse is providing teaching to an older client who has osteoarthritis that is
affecting the knees. What statement by the client indicates a correct
understanding of the teaching?
- A. I can use either heat or ice to help relieve the discomfort
- B. The purpose of drug therapy is to stop the disease progression.'
- C. I will start a daily running program to get more exercise.'
- D. I should avoid physical activity to prevent further injury.'
Correct Answer: A
Rationale:
The nurse is caring for 4 clients. What client should the nurse see first?
- A. A client with multiple children visiting
- B. A client with lupus asking for dinner
- C. A client on Methotrexate with a fever
- D. A client with chronic rheumatic pain
Correct Answer: C
Rationale: The correct answer is the client on Methotrexate with a fever. Fever in a client on Methotrexate, an immunosuppressant, could indicate a serious infection or adverse drug reaction requiring immediate attention to prevent complications. The other choices do not present immediate life-threatening concerns. A client with lupus asking for dinner can wait, a client with chronic rheumatic pain may need pain management but is not the priority over a fever in a client on Methotrexate, and a client with children visiting does not pose an urgent medical issue.