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The nurse is conducting a new-patient assessment on a patient who reports having fibromyalgia. Which of the following would the nurse expect to assess as the most common finding associated with this condition?
- A. Heberden nodes
- B. Jaw locking
- C. Widespread chronic pain
- D. Butterfly facial rash
Correct Answer: C
Rationale: The most common finding associated with fibromyalgia is widespread and chronic pain, as clients experience an increased sensitivity to pain signals. Heberden nodes are associated with osteoarthritis. Jaw locking is a manifestation of temporomandibular joint dislocation. A butterfly facial rash is associated with systemic lupus erythematosus.
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A client is informed of having a benign bone tumor but that this type of tumor may become malignant. The nurse knows that this is characteristic of which type of tumor?
- A. Osteochondroma
- B. Enchondroma
- C. Osteoclastoma
- D. Osteoid osteoma
Correct Answer: C
Rationale: An osteoclastoma is a giant cell tumor that may invade local tissue; usually soft and hemorrhagic and may become malignant. An osteochondroma occurs as a large projection of bone at the ends of long bones, developing during growth periods and then becoming static bone mass. An enchondroma is a hyaline cartilage tumor that develops in the hand, ribs, femur, tibia, humerus, or pelvis. An osteoid osteoma is a painful tumor surrounded by reactive bone tissue.
A client is diagnosed with systemic lupus erythematosus (SLE). Which action would be most appropriate for the nurse to use to evaluate the client's stage of disease?
- A. Observe the client's gait.
- B. Review the client's medical record.
- C. Inspect the client's mouth.
- D. Ausculate the client's lung sounds.
Correct Answer: B
Rationale: The nurse evaluates the stage of SLE and plans appropriate interventions by reviewing the medical record and diagnostic findings of the client. The stage of the disease cannot be established by observing the client's gait, inspecting the client's mouth, or auscultating the client's lung sounds.
A client is taking large amounts of salicylates for the treatment of bursitis of the left shoulder. The client should be aware to report which symptoms of salicylism?
- A. Ringing in the ears
- B. Diarrhea
- C. Dry hacking cough
- D. Dry eyes
Correct Answer: A
Rationale: Signs of salicylate toxicity include headache, nausea, vomiting, tinnitus, increased pulse and respiratory rate, fever, mental confusion, and drowsiness. Dry hacking cough, diarrhea, and dry eyes are not symptoms of salicylate toxicity.
A client is receiving treatment for an acute episode of gout with colchicine. The nurse is administering the medication every 2 hours. What symptom(s) should the nurse be sure the client communicates so that the drug can be temporarily stopped? Select all that apply.
- A. Diarrhea
- B. Tingling in the arms
- C. Intestinal cramping
- D. Increase in pain in the affected extremity
- E. Nausea and vomiting
Correct Answer: A,C,E
Rationale: Colchicine is administered every 1 or 2 hours until the pain subsides or nausea, vomiting, intestinal cramping, and diarrhea develop. When one or more of these symptoms occurs, the drug should be stopped temporarily. Tingling in the arms and increase in pain are not normal adverse reactions that are seen with this drug.
A client diagnosed with degenerative joint disease of the fingers reports now having bumps on the fingers that do not hurt. The nurse observes bony nodules on the distal interphalangeal joints. What type of 'bumps' does the nurse understand these are?
- A. Rheumatoid nodules
- B. Tophi
- C. Bouchard nodes
- D. Heberden nodes
Correct Answer: D
Rationale: DJD affects the hands; the fingers frequently develop painless bony nodules on the dorsolateral surface of the interphalangeal joints. Heberden nodes are bony enlargement of the distal interphalangeal joints. Bouchard nodes are bony enlargement of the proximal interphalangeal joints. Rheumatoid nodules are associated with rheumatoid arthritis. Tophi occur with gout and elevated uric acid levels.