A client grimaces while preforming range of motion of the left knee during an annual health assessment. Which movements should the nurse utilize to assess the client's ability to normally perform range of motion on the right knee?

Adduction, abduction and rotation.

Extension, flexion, and hyperextension.

Internal and external rotation.

Pronation and supination.

Answer and Explanation

The Correct Answer is B

A. Adduction, abduction, and rotation. These movements are more relevant to the hip joint. While rotation can apply to the knee, adduction and abduction do not. These are not the primary movements for assessing knee range of motion.

B. Extension, flexion, and hyperextension. These are the primary movements used to assess the range of motion in the knee joint. Extension and flexion measure the ability of the knee to straighten and bend, respectively. Hyperextension assesses the extent to which the knee can move beyond its normal straight position.

C. Internal and external rotation. While the knee does have some rotational capacity, these movements are limited and not typically used as primary measures of knee range of motion. They are more applicable to hip joint assessments.

D. Pronation and supination. These terms refer to movements of the forearm and wrist, not the knee. They describe the rotational movement of the forearm where the palm turns up (supination) or down (pronation).

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Correct Answer is B

Explanation

A. Use an interpreter throughout the client's hospitalization. Consistently using an interpreter throughout the client's hospitalization ensures clear communication, improves understanding, and enhances the quality of care. However, this answer does not address the specific context of the health assessment interview.

B. Maintain eye contact with client when questions are asked. Maintaining eye contact with the client rather than the interpreter helps build rapport and shows respect and engagement with the client. This practice encourages the client to feel directly involved in the conversation, even though an interpreter is present, fostering a sense of trust and comfort.

C. Ask the interpreter to tell the client to write down questions. This option may be less effective if the client has limited literacy or is uncomfortable with writing. Additionally, it adds an unnecessary step that can complicate the communication process.

D. Give the interpreter a form that lists the interview questions. Providing the interpreter with a list of questions might help streamline the process but can depersonalize the interaction and reduce the engagement with the client. It is more effective for the nurse to ask questions directly and maintain communication with the client.

A. Inspection. B. Auscultation. C. Palpation. D. Percussion.

Correct Answer is A

Explanation

A. Inspection. Papilledema, swelling of the optic disc due to increased intracranial pressure, is primarily assessed through inspection of the optic disc using an ophthalmoscope. The nurse would look for optic disc swelling and blurred disc margins.

B. Auscultation. Auscultation is not appropriate for assessing papilledema, as it involves listening for sounds such as heart, lung, or bowel sounds.

C. Palpation. Palpation is not appropriate for assessing papilledema, as it involves touching and feeling for abnormalities, which would not be possible with the optic disc.

D. Percussion. Percussion is not appropriate for assessing papilledema, as it involves tapping the body surface to elicit sounds or vibrations, which would not provide information about the optic disc.

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A client grimaces while preforming range of motion of the left knee during an annual health assessment. Which movements should the nurse utilize to assess the client's ability to normally perform range of motion on the right knee?

Nursing Test Bank

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Correct Answer is A

Explanation

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A client grimaces while preforming range of motion of the left knee during an annual health assessment. Which movements should the nurse utilize to assess the client's ability to normally perform range of motion on the right knee?