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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.
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A nurse on the orthopedic unit is assessing a patient's peroneal nerve. The nurse will perform this assessment by doing which of the following actions?
- A. Pricking the skin between the great and second toe
- B. Stroking the skin on the sole of the patient's foot
- C. Pinching the skin between the thumb and index finger
- D. Stroking the distal fat pad of the small finger
Correct Answer: A
Rationale: The nurse will evaluate the sensation of the peroneal nerve by pricking the skin centered between the great and second toe. None of the other listed actions elicits the function of one of the peripheral nerves.
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.
A nurse is caring for a patient who has just had an arthroscopy as an outpatient and is getting ready to go home. The nurse should teach the patient to monitor closely for what postprocedure complication?
- A. Fever
- B. Crepitus
- C. Fasciculations
- D. Synovial fluid leakage
Correct Answer: A
Rationale: Following arthroscopy, the patient and family are informed of complications to watch for, including fever. Synovial fluid leakage is unlikely and crepitus would not develop as a postprocedure complication. Fasciculations are muscle twitches and do not involve joint integrity or function.
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.
A nurse is caring for an older adult who has been diagnosed with geriatric failure to thrive. This patient's prolonged immobility creates a risk for what complication?
- A. Muscle clonus
- B. Muscle atrophy
- C. Rheumatoid arthritis
- D. Muscle fasciculations
Correct Answer: B
Rationale: If a muscle is in disuse for an extended period of time, it is at risk of developing atrophy, which is the decrease in size. Clonus is a pattern of rhythmic muscle contractions and fasciculation is the involuntary twitch of muscle fibers; neither results from immobility. Lack of exercise is a risk factor for rheumatoid arthritis.