Nokea
The nurse is gathering objective data for a client at the clinic reporting arthritic pain in the hands. The nurse observes that the fingers are hyperextended at the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. What does the nurse recognize this deformity as?
- A. Swan neck deformity
- B. Boutonniere deformity
- C. Ulnar deviation
- D. Rheumatoid nodules
Correct Answer: A
Rationale: A swan neck deformity is a hyperextension of the proximal interphalangeal joint with fixed flexion of the distal interphalangeal joint. A Boutonniere deformity is a persistent flexion of the proximal interphalangeal joint with hyperextension of the distal interphalangeal joint. Ulnar deviation is when the fingers are deviating laterally toward the ulna. A rheumatoid nodule is a subcutaneous nodule.
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A client is suspected to have Lyme disease and has a red macule at the site of the tick bite with a bull's-eye rash with round rings surrounding the center. In addition, the client has a severe headache with neck stiffness. What stage of Lyme disease does the nurse suspect?
- A. Early stage 1
- B. Mid-stage
- C. Later stage
- D. Latent stage
Correct Answer: A
Rationale: Early stage 1 symptoms for about one third of clients include a red macule or papule at the site of the tick bite, a characteristic bull's-eye rash (called erythema migrans) with round rings surrounding the center, severe headache, and neck stiffness. Mid-stage and later stage symptoms include more systemic involvement like joint pain or neurological symptoms, while the latent stage may be asymptomatic.
A nurse is monitoring a client diagnosed with Lyme disease. Which finding would suggest that the disease is in the early stages?
- A. Breathlessness
- B. Red macule or papule
- C. Bony nodule
- D. Swollen painful knees
Correct Answer: B
Rationale: Early stage 1 symptoms include a red macule or papule at the site of the tick bite, a typical bull's-eye rash, headache, neck stiffness, and pain. Breathlessness and bony nodules are not associated with Lyme disease. Later stage symptoms include swollen and painful knees.
A client is experiencing symptoms that are suspected to be related to systemic lupus erythematosus. What cutaneous symptom occurs in about 50% of clients affected by this disease?
- A. Diffuse purplish lesions on the trunk
- B. Butterfly-shaped rash on the face over the bridge of the nose and cheeks
- C. Fluid-filled vesicles clustered on the cheeks, chin, and forehead
- D. Pustules scattered on the chest and back
Correct Answer: B
Rationale: A prominent sign for about half of the clients with SLE is a red, butterfly-shaped rash known as malar rash, on the face over the bridge of the nose and the cheeks. The word lupus means 'wolf.' The term may have been used as a description for the facial rash that, to some, resembled the mask of reddish-brown fur on a wolf. The other choices are not routinely seen with SLE.
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 is diagnosed with osteomyelitis. This is most commonly caused by which of the following?
- A. Proteus vulgaris
- B. Pseudomonas aeruginosa
- C. Escherichia coli
- D. Staphylococcus aureus
Correct Answer: D
Rationale: Staphylococcus aureus causes over 50% of bone infections. Other organisms include Proteus vulgaris and Pseudomonas aeruginosa, as well as E. coli.