Nokea
While assessing a patient, the patient tells the nurse that she is experiencing rhythmic muscle contractions when the nurse performs passive extension of her wrist. What is this pattern of muscle contraction referred to as?
- A. Fasciculations
- B. Contractures
- C. Effusion
- D. Clonus
Correct Answer: D
Rationale: Clonus may occur when the ankle is dorsiflexed or the wrist is extended. It is characterized as rhythmic contractions of the muscle. Fasciculation is involuntary twitching of muscle fiber groups. Contractures are prolonged tightening of muscle groups and an effusion is the pathologic escape of body fluid.
You may also like to solve these questions
A nurse is taking a health history on a new patient who has been experiencing unexplained paresthesia. What question should guide the nurse's assessment of the patient's altered sensations?
- A. How does the strength in the affected extremity compare to the strength in the unaffected extremity?
- B. Does the color in the affected extremity match the color in the unaffected extremity?
- C. How does the feeling in the affected extremity compare with the feeling in the unaffected extremity?
- D. Does the patient have a family history of paresthesia or other forms of altered sensation?
Correct Answer: C
Rationale: Questions that the nurse should ask regarding altered sensations include How does this feeling compare to sensation in the unaffected extremity? Asking questions about strength and color are not relevant and a family history is unlikely.
A nurse on a patient has been experiencing significant pain in her knee and diagnostic imaging reveals an effusion in the synovial capsule. What intervention should the nurse anticipate?
- A. Arthrography
- B. Knee replacement
- C. Arthrocentesis
- D. Arthroscopy
Correct Answer: C
Rationale: Arthrocentesis (joint aspiration) is carried out to obtain synovial fluid for examination or to relieve pain due to effusion. Arthrography is used to visualize joint structures, not to remove fluid. Arthroscopy is a diagnostic visualization, and knee replacement is not indicated for effusion.
A nurse is caring for a patient whose cancer metastasis has resulted in bone pain. Which of the following are typical characteristics of bone pain?
- A. A dull, deep ache that is boring in nature
- B. Soreness or aching that may include cramping
- C. Sharp, piercing pain that is relieved by immobilization
- D. Spastic or sharp pain that radiates
Correct Answer: A
Rationale: Bone pain is characteristically described as a dull, deep ache that is boring in nature, whereas muscular pain is described as soreness or aching and is referred to as muscle cramps. Fracture pain is sharp and piercing and is relieved by immobilization. Sharp pain may also result from bone infection with muscle spasm or pressure on a sensory nerve.
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 caring for a patient with a diagnosis of cancer that has metastasized. What laboratory value would the nurse expect to be elevated in this patient?
- A. Bilirubin
- B. Potassium
- C. Alkaline phosphatase
- D. Creatinine
Correct Answer: C
Rationale: Alkaline phosphatase is elevated during early fracture healing and in diseases with increased osteoblastic activity (e.g., metastatic bone tumors). Elevated bilirubin, potassium, and creatinine would not be expected in a patient with metastatic bone tumors.