Nokea
A nurse is performing a musculoskeletal assessment of a patient with arthritis. During passive range-of-motion exercises, the nurse hears an audible grating sound. The nurse should document the presence of which of the following?
- A. Fasciculations
- B. Clonus
- C. Effusion
- D. Crepitus
Correct Answer: D
Rationale: Crepitus is a grating, crackling sound or sensation that occurs as the irregular joint surfaces move across one another, as in arthritic conditions. Fasciculations are involuntary twitching of muscle fiber groups. Clonus is the rhythmic contractions of a muscle. Effusion is the collection of excessive fluid within the capsule of a joint.
You may also like to solve these questions
A nurse is assessing a patient who is experiencing peripheral neurovascular dysfunction. What assessment findings are most consistent with this diagnosis?
- A. Hot skin with a capillary refill of 1 to 2 seconds
- B. Absence of feeling, capillary refill of 4 to 5 seconds, and cool skin
- C. Pain, diaphoresis, and erythema
- D. Jaundiced skin, weakness, and capillary refill of 3 seconds
Correct Answer: B
Rationale: Indicators of peripheral neurovascular dysfunction include pale, cyanotic, or mottled skin with a cool temperature; capillary refill greater than 3 seconds; weakness or paralysis with motion; and paresthesia, unrelenting pain, pain on passive stretch, or absence of feeling. Jaundice, diaphoresis, and warmth are inconsistent with peripheral neurovascular dysfunction.
A nurse is assessing a child who has a diagnosis of muscular dystrophy. Assessment reveals that the child's muscles have greater-than-normal tone. The nurse should document the presence of which of the following?
- A. Tonus
- B. Flaccidity
- C. Atony
- D. Spasticity
Correct Answer: D
Rationale: A muscle with greater-than-normal tone is described as spastic. Soft and flabby muscle tone is defined as atony. A muscle that is limp and without tone is described as being flaccid. The state of readiness known as muscle tone (tonus) is produced by the maintenance of some of the muscle fibers in a contracted state.
An older adult patient has come to the clinic for a regular check-up. The nurse's initial inspection reveals an increased thoracic curvature of the patient's spine. The nurse should document the presence of which of the following?
- A. Scoliosis
- B. Epiphyses
- C. Lordosis
- D. Kyphosis
Correct Answer: D
Rationale: Kyphosis is the increase in thoracic curvature of the spine. Scoliosis is a deviation in the lateral curvature of the spine. Epiphyses are the ends of the long bones. Lordosis is the exaggerated curvature of the lumbar spine.
A patient has just had an arthroscopy performed to assess a knee injury. What nursing intervention should the nurse implement following this procedure?
- A. Wrap the joint in a compression dressing.
- B. Perform passive range of motion exercises.
- C. Maintain the knee in flexion for up to 30 minutes.
- D. Apply heat to the knee.
Correct Answer: A
Rationale: Interventions to perform following an arthroscopy include wrapping the joint in a compression dressing, extending and elevating the joint, and applying ice or cold packs. Passive ROM exercises, static flexion, and heat are not indicated.
A nurse is caring for a patient who has been scheduled for a bone scan. What should the nurse teach the patient about this diagnostic test?
- A. The test is brief and requires that you drink a calcium solution 2 hours before the test.
- B. You will not be allowed fluid for 2 hours before and 3 hours after the test.
- C. You'll be encouraged to drink water after the administration of the radioisotope injection.
- D. This is a common test that can be safely performed on anyone.
Correct Answer: C
Rationale: It is important to encourage the patient to drink plenty of fluids to help distribute and eliminate the isotopic after it is injected. There are important contraindications to the procedure, include pregnancy or an allergy to the radioisotope. The test requires the injection of an intravenous radioisotope and the scan is preformed 2 to 3 hours after the isotope is injected. A calcium solution is not utilized.