The nurse is performing a musculoskeletal assessment and notes that the patient has a tender, swollen joint with decreased range of motion. What is the most likely diagnosis?

Correct Answer: B

Rationale: The correct answer is B: Rheumatoid arthritis. This diagnosis is supported by the presence of tender, swollen joint with decreased range of motion which are typical symptoms of rheumatoid arthritis. In this condition, the body's immune system attacks the joints, causing inflammation, pain, and limited movement. Osteoarthritis (A) typically presents with joint pain and stiffness, but not usually with significant swelling. Gout (C) is characterized by sudden and severe pain, redness, and swelling in joints, often affecting the big toe. Bursitis (D) is inflammation of the bursae sacs, causing pain and swelling around joints, but typically without significant limitation in range of motion.

Correct Answer: A

Rationale: Pain stimulates the sympathetic nervous system, often increasing pulse rate as the body responds to stress, a common finding in acute abdominal pain. A decrease in body temperature isnt typical, as pain may elevate temperature if inflammation is present. A decrease in blood pressure could occur in shock but isnt a primary pain response; pain often increases blood pressure initially. An increase in respiratory depth (D replaced with E) and rate (E) may occur, but the correct answer focuses on A. Pain typically accelerates pulse and respiratory rate while potentially decreasing depth, not increasing it. Choice A is correct as it consistently aligns with physiological responses to severe pain, supported by clinical observations of tachycardia in painful conditions like appendicitis or perforation.

Correct Answer: D

Rationale: Arrhythmias disrupt peripheral pulse reliability, requiring a central site. Brachial and radial are peripheral, potentially missing beats. Dorsalis pedis is distal, less accurate for arrhythmias. Apical at the heart apex directly counts beats, unaffected by peripheral irregularities, making it correct. Choice D is standard for arrhythmia patients, ensuring accurate rate and rhythm assessment per cardiovascular nursing protocols.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) 80 for the pulse pressure. Pulse pressure is calculated by subtracting the diastolic blood pressure (the bottom number) from the systolic blood pressure (the top number). In this case, 140 (systolic) - 60 (diastolic) = 80 (pulse pressure). Option A) 60 is the diastolic blood pressure value, not the pulse pressure. Option C) 140 is the systolic blood pressure value, not the pulse pressure. Option D) 200 does not align with any component of blood pressure in this context. Educationally, it is crucial for nurses to understand how to calculate and interpret vital signs accurately as they provide essential information about a patient's health status. Pulse pressure is a significant indicator of cardiovascular health, reflecting the difference between the force of the blood pumped out of the heart during systole and the resting pressure during diastole. By correctly interpreting pulse pressure, nurses can assess a patient's cardiovascular function and potentially identify conditions such as hypertension or heart failure.

Correct Answer: B

Rationale: Hypothermia is a core temperature below 95°F (35°C), but 96.8°F (36°C) is a practical threshold for early detection . An increase over 96.8°F suggests normothermia or fever. Cyanosis is a symptom, not hypothermia. ‘None' is incorrect. Choice B is correct, aligning with nursing definitions (e.g., CDC) where subnormal temperature signals risk, guiding interventions like warming to prevent complications.