Osteoarthritis

A 63 year old patient has severe osteoarthritis in the right knee. The patient is scheduled for a knee osteotomy. You are providing pre-op teaching about this procedure to the patient. Which statement made by the patient is correct about this procedure? A. "This procedure will realign the knee and help decrease the amount of weight experienced on my right knee." B. "A knee osteotomy is also called a total knee replacement." C. "A knee osteotomy is commonly performed for patients who have osteoarthritis in both knees." D. "This procedure will realign the unaffected knee and help alleviate the amount of weight experienced on the right knee."

A. "This procedure will realign the knee and help decrease the amount of weight experienced on my right knee."

Which patients below are at risk for developing osteoarthritis? Select-all-that-apply: Which patients below are at risk for developing osteoarthritis? Select-all-that-apply: A. A 65 year old male with a BMI of 35. B. A 59 year old female with a history of taking long term doses of corticosteroids. C. A 55 year old male with a history of repeated right knee injuries. D. A 60 year old female with high uric acid levels.D. A 60 year old female with high uric acid levels.

A. A 65 year old male with a BMI of 35. C. A 55 year old male with a history of repeated right knee injuries.

A patient with osteoarthritis is describing their signs and symptoms. Which signs and symptoms below are NOT associated with osteoarthritis? Select-all-that-apply: A. Morning stiffness greater than 30 minutes B. Experiencing grating during joint movement C. Fever and Anemia D. Symmetrical joint involvement E. Pain and stiffness tends to be worst at the end of the day

A. Morning stiffness greater than 30 minutes C. Fever and Anemia D. Symmetrical joint involvement

A client with possible osteoarthritis is scheduled for a synovial fluid analysis. The nurse should explain to the client that this diagnostic test is being completed for which​ reason? A. To rule out inflammatory arthritis and gout B. To identify irregular joint space narrowing C. To evaluate for increased density of subchondral bone D. To determine the extent of joint damage

Answer: A ​Rationale: Joint fluid analysis is used to detect​ inflammation, bacteria, and uric acid crystals to rule out inflammatory arthritis and gout. This test will not provide information on the extent of the joint damage. This test cannot identify the amount of joint space that has narrowed. This test cannot evaluate bone density.

Which health promotion activity supports a healthy lifestyle for clients with​ osteoarthritis? (Select all that​ apply.) A. Maintaining a normal weight B. Using proper body mechanics C. Using assistive devices as needed D. Increasing dietary intake of calcium E. Using soft chairs and recliners for rest

Answer: A, B, C ​Rationale: Maintaining a normal weight places less strain on the joints than carrying additional weight. Assistive devices such as grab​ bars, a shower​ chair, or​ long-handled grippers help the client to maintain an independent lifestyle in safety. Using proper body mechanics during activities reduces stress on joints. Although calcium intake is essential for preventing​ osteoporosis, especially in older​ adults, increasing daily calcium intake does not have a positive effect on OA. Chairs and mattresses should provide support and help to maintain normal body alignment. Soft chairs and recliners do not provide such support.

The nurse is providing teaching about home care for a client with osteoarthritis of the knees. Which information should the nurse​ include? (Select all that​ apply.) A. Installing handrails in the bathroom B. Using assistive devices to minimize stress placed on affected joint C. Taking pain medications as ordered D. Continuing activity with repetitive movement E. Encouraging heavy lifting to maintain muscle strength

Answer: A, B, C ​Rationale: Taking pain medications as ordered will assist with pain management and allow the client to participate in daily activities. Installing handrails in the bathroom is information that the nurse should include when educating a client to keep the client safer during activities of daily living at home. The nurse should educate the client on the importance of using assistive devices to minimize joint stress. The nurse should instruct the client to avoid repetitive movement and to avoid heavy​ lifting, because these actions will increase pain and joint degeneration and will not improve physical mobility.

Which is a common risk factor for​ osteoarthritis? (Select all that​ apply.) A. Overuse of joints from sports or strenuous activities B. Obesity C. Ingestion of large amounts of purine D. Autoimmune disorder E. Activities affecting​ weight-bearing joints

Answer: A, B, E ​Rationale: Common risk factors for osteoarthritis include​ obesity, overuse of joints from sports injuries or strenuous​ activities, and activities affecting​ weight-bearing joints. Rheumatoid arthritis is thought to be an autoimmune disorder. Ingestion of large amounts of purines is a risk factor for gout.

Which clinical manifestation of osteoarthritis​ (OA) should the nurse include when teaching about​ osteoarthritis? (Select all that​ apply.) A. Joint pain with activity B. Pain and stiffness at night C. Abrupt onset D. Mild fever E. Crepitus with movement of joint

Answer: A, B, E ​Rationale: Joint pain with​ activity, grating or crepitus noted with​ movement, and pain and stiffness with prolonged inactivity are general manifestations of OA. Mild fever is associated with rheumatoid​ arthritis, not OA. Osteoarthritis is a degenerative disease that develops over​ time, although symptoms may appear suddenly.

Which health promotion activity supports a healthy lifestyle for clients with​ osteoarthritis? (Select all that​ apply.) A. Maintaining a normal weight B. Using proper body mechanics C. Using assistive devices as needed D. Increasing dietary intake of calcium E. Using soft chairs and recliners for rest

Answer: A, C ​Rationale: Maintaining a normal weight places less strain on the joints than carrying additional weight. Assistive devices such as grab​ bars, a shower​ chair, or​ long-handled grippers help the client to maintain an independent lifestyle in safety. Using proper body mechanics during activities reduces stress on joints. Although calcium intake is essential for preventing​ osteoporosis, especially in older​ adults, increasing daily calcium intake does not have a positive effect on OA. Chairs and mattresses should provide support and help to maintain normal body alignment. Soft chairs and recliners do not provide such support.

Which surgical treatment should the nurse anticipate may be offered to clients with osteoarthritis who cannot be managed with traditional​ treatment? (Select all that​ apply.) A. Arthroplasty B. Serum hyaluronic acid C. Joint fusion D. Cortisone therapy E. Osteotomy

Answer: A, C, E ​Rationale: Arthroplasty,​ osteotomy, and joint fusion are all surgical interventions indicated for a client with osteoarthritis. Serum hyaluronic acid is a diagnostic blood test for knee osteoarthritis and is not a surgical treatment. Cortisone therapy is not a surgical​ treatment; it is injected into the inflamed joint.

The parents of a child newly diagnosed with juvenile osteoarthritis​ (OA) are concerned about their​ child's future ability to be disability free and remain independent. Which information should the nurse give the​ parents? (Select all that​ apply.) A. ​"Children may outgrow OA as they​ age." B. ​"OA in children is​ generalized, thus impacting all joints and increasing possible​ impairment." C. "The amount of disability will depend on how well the OA is managed as a​ child." D. "OA in children is usually​ idiopathic, making it difficult to determine how it will affect them as​ adults." E. ​"Children with OA are less likely to become​ disabled."

Answer: A, E ​Rationale: Children with OA are less likely to become disabled as adults and may outgrow the OA as they age. It is not likely that children with OA will be disabled as adults.

A​ 32-year-old client who has limited hip joint damage from osteoarthritis asks the nurse why an osteotomy is being performed rather than other procedures. Which response by the nurse provides the most accurate​ information? A. "This procedure is usually tried​ first; arthroplasty will be done later if this does not​ work." B. "This procedure can be done since you are young and healthy and your hip damage is​ limited." C. ​"This procedure prepares you for joint resurfacing and a total hip replacement later in​ life." D. "An osteotomy is much less invasive than all of the other​ procedures."

Answer: B ​Rationale: An osteotomy is performed to realign the joint or to shift the joint load toward areas of less cartilage damage. It is used instead of joint replacement surgery if the client is​ young, healthy, and damage is limited to only one side of the joint. This would provide the most accurate explanation to the client. It is not indicated as a surgery to necessarily be done first before an​ arthroplasty, nor to prepare the client for joint resurfacing surgery.

The nurse is planning care for a client with osteoarthritis​ (OA). Which nursing diagnosis is a priority for the nurse to​ address? A. Lifestyle, Sedentary B. ​Pain, Chronic C. Skin​ Integrity, Impaired D. Family​ Processes, Interrupted

Answer: B ​Rationale: Chronic pain is the priority problem for the nurse to address when planning care for a client diagnosed with osteoarthritis. Sedentary lifestyle would be a concern because exercise can help to address OA but would not be a priority nursing diagnosis. Skin integrity and impaired family processes are not expected problems for the nurse to address when planning care for a client diagnosed with OA.

After performing a physical​ assessment, the nurse suspects that a client is experiencing manifestations of osteoarthritis​ (OA). Which finding supports the​ nurse's suspicion?​ (Select all that​ apply.) A. Leg tremors B. Joint tenderness C. Reduced joint flexibility D. Crepitation E. Joint stiffness

Answer: B, C, D, E ​Rationale: Manifestations of OA include crackling​ sounds, or​ crepitation, with joint​ movement; joint stiffness and​ tenderness; and reduced joint flexibility. Leg tremors can be associated with multiple sclerosis or Parkinson disease.

The nurse is teaching older adults with osteoarthritis​ (OA) actions to effectively manage chronic pain. Which recommendation should the nurse​ include? (Select all that​ apply.) A. Limiting isometric exercises to reduce strain on the joints B. Using firm support in chairs and mattresses to properly align the body C. Applying cool compresses to painful joints to reduce inflammation D. Teaching proper posture and good body mechanics for activities of mobility E. Encouraging resting painful joints

Answer: B, D, E ​Rationale: Chronic pain is frequently associated with OA. When joints are​ painful, they should be rested. The rest should be balanced with periods of​ activity, which will reduce joint stiffness. Using proper posture and good body mechanics places the body in proper alignment and offers the joints a neutral platform to perform range of motion activities. Firm chairs and mattresses assist the body in proper alignment. Heat should be applied to painful​ joints, which will increase joint mobility. Cool compresses may increase joint pain and will limit joint mobility. Isometric exercises strengthen muscle​ groups, which is important to provide additional strength in movement. Strong muscles will reduce strain on joints.

The nurse is teaching a class about the joints commonly affected by osteoarthritis​ (OA). Which joints should the nurse​ include? A. Ankles, feet, and spine B. Knees, feet, and spine C. Hands, knees, and hips D. Neck, shoulders, and ankles

Answer: C ​Rationale: Hands,​ knees, and hips are the most commonly affected joints of OA.​ Feet, spine,​ neck, shoulders, and ankles are not the most common locations.

The nurse is evaluating a client who has osteoarthritis (OA) of the hips and knees. Which statement by the client indicates progress toward meeting identified activity​ goals? A. "I've increased my running time to 30 minutes 3 times a week and use orthotics in my​ sneakers." B. "I have been completing the range of motion​ (ROM) exercises for all joints every other​ day." C. "I've been able to manage my pain so that I can independently complete my daily​ activities." D. "I limit the use of acetaminophen unless I absolutely need it to decrease my risk of liver​ toxicity."

Answer: C ​Rationale: Successful management of pain so that the client with OA can independently complete daily activities indicates progress toward an important goal. ROM should be done every day for all joints. Acetaminophen should be used regularly to help avoid severe pain from occurring. Running is a​ high-impact activity that can increase stress on joints.​ Low-activity aerobic​ exercise, not​ high-impact exercise, should be included in activity goals for the client with OA.

A client with osteoarthritis asks the nurse how to decrease wrist swelling. Which intervention should the nurse​ suggest? A. Increasing range of motion exercises for that joint to 3 times a day B. Applying a warm towel to the wrist joint 3 times per day for 20 minutes at a time C. Using compression cold packs to provide a deeper cold to the wrist joint D. Encouraging use of assistive devices during daily activities to decrease stress on the joint

Answer: C ​Rationale: The use of deep cold can best help to address swelling. Increasing ROM exercises to 3 times a day is not the best approach to decrease​ swelling; ROM helps to maintain flexibility of the joint. Heat decreases pain and increases​ flexibility; it does not address swelling. Assistive device use can decrease stress on the joint to possibly prevent​ swelling, but it would not be the best approach to address swelling once it has occurred.

A client diagnosed with localized idiopathic osteoarthritis​ (OA) asks the nurse what this means. Which response by the nurse provides the most accurate​ information? A. "Idiopathic describes OA overall while localized indicates that it affects one body joint​ only." B. "Idiopathic refers to the fact that the OA has already progressed significantly in one or two​ joints." C. "Idiopathic OA has no identifiable​ cause; when it is​ localized, it only affects one or two​ joints." D. ​"Idiopathic OA, as compared with secondary​ OA, is caused by some kind of underlying​ condition."

Answer: C ​Rationale: There are two types of​ OA, idiopathic and secondary. Idiopathic OA has no identifiable cause and can be further subdivided as localized or​ generalized, with localized indicating that the OA only affects one or two​ joints, so stating that it has no identifiable cause and is limited to one or two joints would be the most accurate response. Idiopathic OA is not due to an underlying condition. Idiopathic refers to​ cause, not progression of the disease. Idiopathic is not a term used in general for​ OA, nor does the term localized indicate that affected joints are either in the upper or lower torso.

The nurse is counseling a newly pregnant client with osteoarthritis​ (OA). Which information should the nurse​ include? A. "Pregnancy has no impact on OA if you keep your weight gain within the recommended​ limits." B. ​"You need to restrict your participation in​ low-impact aerobic​ exercises." C. "Your pain from the OA may increase due to the weight gain of​ pregnancy." D. "You may continue to take your prescription nonsteroidal​ anti-inflammatory drug without any risk of harm to the​ fetus."

Answer: C ​Rationale: Weight gain of pregnancy may increase the pain resulting from OA due to the increased stress on the​ joints; this would be important information to include. The impact of nonsteroidal​ anti-inflammatory drugs, such as celecoxib​ (Celebrex), on the fetus is​ unknown; the nurse would not tell the client that it is safe to use.​ Low-impact aerobic exercises are recommended for clients with OA. The recommended weight gain for pregnancy would not be changed due to the​ OA, nor is it valid to indicate that pregnancy will have no impact on the OA.

Which assistive device should the nurse recommend to a client with osteoarthritis​ (OA) of the​ hands? (Select all that​ apply.) A. Handrails B. Reacher device C. Electric can opener D. Zipper hook E. Large-handled toothbrush

Answer: C, D, E ​Rationale: Zipper​ hooks, electric can​ openers, and​ large-handled toothbrushes can be helpful for clients with OA of the hands. Handrails can be useful for clients with OA of the hips. Reacher devices can be helpful for clients with OA of the shoulders.

The nurse is teaching an older adult recently diagnosed with osteoarthritis​ (OA) about interventions to help maintain mobility of the joints. Which should the nurse​ include? A. Jogging three times a week B. Routine nonsteroidal​ anti-inflammatory drug​ (NSAID) use C. Glucosamine and chondroitin supplements D. Physical therapy

Answer: D ​Rationale: Physical therapy is particularly important for older adults with OA to help them maintain or improve joint mobility. NSAIDs should generally not be used by older adults due to the risks associated with their use. Older adults should use acetaminophen as a​ first-line drug and narcotics as a​ second-line choice. Jogging is a​ high-impact activity that could place more stress on the joints and would not be recommended. The utility of supplements has not been supported as​ effective; additionally, the use of glucosamine and chondroitin may increase the risk of bleeding.

The nurse is assessing an older adult who has osteoarthritis​ (OA). Which finding indicates the impact of​ OA? A. Sitting in a soft chair and not getting up to greet the nurse B. Requesting a dose of acetaminophen to address joint pain C. Asking the nurse to retrieve items from across the room D. Leaning on furniture while walking

Answer: D ​Rationale: When assessing the client with​ OA, the nurse should observe how the client moves and ambulates. Noting that the client leans on furniture while walking indicates possible issues related to the OA. Asking the nurse to retrieve items from across the​ room, requesting a dose of​ acetaminophen, and not getting up when the nurse arrives do not provide any direct observable data to indicate the possible impact of OA on the client.

At what age does osteoarthritis primarily begins? A. 20 years old B. 30 years old C. 60 years old D. 40 years old

B. 30 years old OA often begins with the third decade of life and peaks between the fifth and the sixth decades.

During a head-to-toe assessment of a patient with osteoarthritis, you note bony outgrowths on the distal interphalangeal joints. You document these findings as: A. Bouchard's Nodes B. Heberden's Nodes C. Neurofibromatosis D. Dermatofibromas

B. Heberden's Nodes

You receive your patient back from radiology. The patient had an x-ray of the hips and knees for the evaluation of possible osteoarthritis. What findings would appear on the x-ray if osteoarthritis was present? Select-all-that-apply: A. Increased joint space B. Osteophytes C. Sclerosis of the bone D. Abnormal sites of hyaline cartilage

B. Osteophytes C. Sclerosis of the bone

A patient with osteoarthritis has finished their first physical therapy session. As the nurse you want to evaluate the patient's understanding of the type of exercises they should be performing regularly at home as self-management. Select all the appropriate types of exercise stated by the patient: A. Jogging B. Water aerobics C. Weight Lifting D. Tennis E. Walking

B. Water aerobics C. Weight Lifting E. Walking

The most common type of disabling connective tissue disease in the United States is: A. Carpal tunnel syndrome. B. Degenerative joint disease. C. Fibrositis. D. Polymyositis.

B: Degenerative joint disease is the most common and most disabling connective tissue disease in the United States.

Pathophysiologic changes seen with osteoarthritis include: A. Joint cartilage degeneration. B. The formation of bony spurs at the edges of the joint surfaces. C. Narrowing of the joint space. D. All of the above.

C. Narrowing of the joint space.

A patient newly diagnosed with osteoarthritis asks about the medication treatments for their condition. Which medication is NOT typically prescribed for OA? A. NSAIDs B. Topical Creams C. Oral corticosteroids D. Acetaminophen (Tylenol)

C. Oral corticosteroids

The diagnostic test that reveals the narrowing of the joint space is: A. MRI B. CT Scan C. X-ray D. Physical assessment

C. X-ray OA is characterized by a progressive loss of joint cartilage, which appears on x-ray as a narrowing of the joint space.

What are the classifications of osteoarthritis? A. Idiopathic B. Primary C. Secondary D. All of the above

D. All of the above The classifications of osteoarthritis include primary or idiopathic and secondary osteoarthritis.

Osteoarthritis develops due to the deterioration of the synovium within the joint that can lead to complete bone fusion. True False

FALSE

The 20 year old female client diagnosed with advanced unremitting RA is being admitted to receive a regimen of immunosuppressive medications. Which question should the nurse ask during the admission process regarding the medications? a. "Are you sexually active, and if so, are you using birth control?" b. "Have you discussed taking these drugs with your parents?" c. "Which arm do you prefer to have an IV in for 4 days?" d. "Have you signed an informed consent for investigational drugs?"

a. "Are you sexually active, and if so, are you using birth control?"

The occupational health nurse is teaching a class on the risk factors for developing OA. Which is a modifiable risk for developing OA? a. Being overweight b. Increasing age c. Previous joint damage d. Genetic susceptibility

a. Being overweight

The client with RA has nontender movable nodules in subcutaneous tissue over the elbows and shoulders. Which statement is the best explanation for the nodules? a. The nodules indicate a rapidly progressive destruction of the affected tissue b. The nodules are small amounts of synovial fluid that have become crystallized c. The nodules are lymph nodes that have proliferated to try to fight the disease d. The nodules present a favorable prognosis and mean the client is better

a. The nodules indicate a rapidly progressive destruction of the affected tissue

The nurse is preparing to administer morning medications. Which medication should the nurse administer first? a. The pain medication to a client diagnosed with RA b. The diuretic medication to a client diagnosed with Lupus (SLE) c. The steroid to a client diagnosed with polymyositis d. The appetite stimulant to a client diagnosed with OA

a. The pain medication to a client diagnosed with RA

. The client diagnosed with RA who has been prescribed Plaquenil, shows marked improvement. Which instruction regarding the use of this medication should the nurse teach? a. Explain that the less medication loses its efficacy after a few months b. Continue to have regular eye exams while taking the medication c. Have yearly MRIs to follow the progress d. Discuss that the drug is taken for 3 weeks and then stopped for a week

b. Continue to have regular eye exams while taking the medication

5. The client is diagnosed with osteoarthritis. Which sign/symptom would the nurse expect the client to exhibit? a. Severe bone deformity b. Joint stiffness c. Waddling gait d. Swan neck fingers

b. Joint stiffness

Which client goal would be most appropriate for a client diagnosed with OA? a. Perform passive range-of-motion exercises b. Maintain optimal functional ability c. Client will walk three miles a day d. Client will join a health club

b. Maintain optimal functional ability

The client diagnosed with RA has developed swan-neck fingers. Which referral would be the most appropriate for the client? a. Physical therapy b. Occupational therapy c. Psychiatric counselor d. Home health nurse

b. Occupational therapy

The nurse is admitting the client with OA to the medical floor. Which statement by the client indicates a complementary form of treatment for OA? a. "I take medication every two hours for my pain" b. "I use a heating pad when I go to bed at night" c. "I wear a copper bracelet to help with my OA" d. "I always wear my ankle splints when I sleep"

c. "I wear a copper bracelet to help with my OA"

Which client problem is priority for a client diagnosed with RA? a. Activity intolerance b. Fluid and Electrolyte balance c. Alteration in comfort d. Excessive nutritional intake

c. Alteration in comfort

Which member of the health care team should the nurse refer the client diagnosed with OA who is complaining of not being able to get in and out of the bathtub? a. Physiatrist b. Social worker c. Physical therapist d. Counselor

c. Physical therapist

The client diagnosed with RA is receiving care through a nurse practitioner clinic. Which preventive care should the nurse include in the regularly scheduled clinic visits? a. Perform joint x-rays to determine progression of the disease b. Send blood to the lab for an erythrocyte sedimentation rate (ESR) c. Recommend the flu and pneumonia vaccines d. Assess the client for increasing joint involvement

c. Recommend the flu and pneumonia vaccines

The nurse is caring for clients on a medical floor. Which client should the nurse assess first? a. The client diagnosed with RA who is complaining of pain at a "3" on a 1-10 scale b. The client diagnosed with Systemic Lupus Erythematosus who has a rash across the bridge of the nose c. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV d. The client diagnosed with scleroderma who has hard, waxylike skin near the eyes

c. The client diagnosed with advanced RA who is receiving antineoplastic drugs IV

The client diagnosed with OA is a resident in a long term care facility. The resident is refusing to bathe because she is hurting. Which instruction should the nurse give the unlicensed nursing assistant? a. Allow the client to stay in bed until the pain becomes bearable b. Tell the assistant to give the client a bed bath this morning c. Try to encourage the client to get up and go to the shower d. Notify the family that the client is refusing to be bathed

c. Try to encourage the client to get up and go to the shower

The client is complaining of joint stiffness, especially in the morning. Which diagnostic tests would the nurse expect the HCP to order to R/O OA? a. Full body MRI scan b. Serum studies for synovial fluid amount c. X-ray of the affected joints d. Serum erythrocyte sedimentation rate (ESR)

c. X-ray of the affected joints

The client recently diagnosed with RA is prescribed aspirin, an NSAID medication. Which comment by the client would warrant immediate intervention by the nurse a. "I always take the aspirin with food" b. "If I have dark stools, I will call my HCP" c. "Aspirin will not cure my arthritis" d. "I am having some ringing in my ears"

d. "I am having some ringing in my ears"

Which psychosocial problem would be priority for a client diagnosed with RA? a. Alteration in comfort b. Ineffective coping c. Anxiety d. Altered body image

d. Altered body image

21. The client with early-stage RA is being discharged from the outpatient clinic. Which discharge instructions should the nurse teach regarding the use of NSAIDs? a. Take an over-the-counter medication for the stomach b. Drink a full glass of water with each pill c. If a dose is missed, double the medication at the next dosing time d. Avoid taking the NSAID on an empty stomach

d. Avoid taking the NSAID on an empty stomach

2. The client has been diagnosed with OA for the last 7 years and has tried multiple medical treatments and alternative treatments but still has significant joint pain. Which psychosocial client problem would the nurse identify? a. Severe pain b. Body-image disturbance c. Knowledge deficit d. Depression

d. Depression

The client diagnosed with OA is prescribed a NSAID. Which instruction should the nurse teach the client? a. Take the medication on an empty stomach b. Make sure the client tapers the medication when discontinuing c. Apply the medication topically over the affected joints d. Notify the HCP if vomiting blood

d. Notify the HCP if vomiting blood

Which intervention has the highest priority when caring for a client diagnosed with RA? a. Encourage the client to ventilate feelings about the disease process b. Discuss the effects of disease on the client's career and other life roles c. Instruct the client to perform most important activities in the morning d. Teach the client the proper use of hot and cold therapy to provide pain relief

d. Teach the client the proper use of hot and cold therapy to provide pain relief

. The nurse is assessing a client diagnosed with RA. Which assessment findings warrant immediate intervention? a. The client complains of joint stiffness and the knees feel warm to the touch b. The client has experienced one kg weight loss and is very tired c. The client requires a heating pad applied to the hips and back to sleep d. The client is crying, has a flat facial affect, and refuses to speak to the nurse

d. The client is crying, has a flat facial affect, and refuses to speak to the nurse