The nurse is assessing a client with inflammation of the right ...

[newbem]

The nurse is assessing a client with inflammation of the right knee. In order to determine whether the inflammation has becomes systemic, the nurse should assess:
 
  1. the eyes for jaundice.
  2. the lymph nodes in the groin.
  3. the client's level of pain.
  4. swelling in the arms.

Question 2

During an admission assessment the nurse learns that an older client experiences leg soreness. What should this information indicate to the nurse? (Select all that apply.)
 
  1. All older clients have body soreness.
  2. The client needs to be assessed for pain.
  3. The client could be denying the presence of pain.
  4. Body soreness is an expected assessment finding with an older client.
  5. Additional information is needed about the use of over-the-counter medications.

[nekcihc358]

Answer to Question 1

Answer: 2

1. Jaundice in the eyes is an indication of liver failure.
2. If the lymph nodes, particularly in the groin, are swollen, the nurse should be concerned that the inflammation has become systemic.
3. The client's level of pain does not indicate local or systemic inflammation.
4. Swelling in the arms is a local response to inflammation and would not be associated with the inflammation of the knee.

Answer to Question 2

Answer: 2, 3, 5

1. All older clients do not have body soreness.
2. Older clients may report pain as being soreness.
3. Older clients may deny the presence of pain and use the term soreness instead.
4. Body soreness is not an expected assessment finding with an older client.
5. Since older clients may deny pain, the use of over-the-counter pain medications needs to be assessed.