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Question 1 of 5

The nurse is assessing a client with suspected rheumatoid arthritis. Which of the following findings would support this diagnosis?

Correct Answer: A

Rationale: Morning stiffness lasting over 30 minutes is a hallmark of rheumatoid arthritis due to synovial inflammation. Heberden’s nodes (
B) indicate osteoarthritis, single-joint pain (
C) suggests injury, and fever/weight loss (
D) are nonspecific without joint involvement.

Question 2 of 5

A nurse is providing care for an elderly patient with dementia. Which of the following interventions is most appropriate?

Correct Answer: B

Rationale: A structured routine reduces confusion and promotes safety in dementia. Complex decisions overwhelm, social interactions benefit, and activity supports health.

Question 3 of 5

A patient with borderline personality disorder is exhibiting self-harming behaviors. Which of the following interventions is most appropriate?

Correct Answer: B

Rationale: Providing immediate medical care for injuries ensures safety and addresses physical harm, the priority in self-harming behaviors. Ignoring, punishing, or only discussing feelings delays critical intervention.

Question 4 of 5

The nurse assesses a client who gave birth 24 hours earlier. Which of the following findings reveals the need for further evaluation?

Correct Answer: B

Rationale: During the early postpartum period, lochia rubra should be moderate to significant. Scant lochia rubra suggests that large clots are blocking the lochial flow. After delivery, vasomotor changes may cause a shaking chill. Thirst, fatigue, and a temperature of up to 100.4°F (38°
C) also are common at 24 hours postpartum.

Question 5 of 5

The nurse is performing a baseline assessment of a client's skin integrity. Which of the following is a key assessment parameter?

Correct Answer: D

Rationale: When assessing skin integrity, the overall risk potential for developing pressure ulcers takes priority. Overall risk encompasses existing pressure ulcers as well as potential areas for development of pressure ulcers. Family history isn't important when assessing skin integrity.

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