A client states “I can hear a crunching or grating sound when I kneel and have difficulty getting out the bed in the morning because of pain and stiffness”. Which of the following should the nurse expect as an assessment finding?
Bone spur
Crepitation
Tendonitis
Fluid in the knee joint
The Correct Answer is B
Choice A rationale: While a bone spur could contribute to joint symptoms, the description provided by the client is more indicative of crepitation.
Choice B rationale: The client's complaint of a crunching or grating sound when kneeling and difficulty getting out of bed in the morning is indicative of crepitation, which is often associated with joint degeneration.
Choice C rationale: Tendonitis typically presents with inflammation and pain associated with specific tendons but may not produce a crunching sound.
Choice D rationale: Fluid in the knee joint (effusion) may cause swelling and limited range of motion but may not necessarily produce crepitation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale: The normal liver span is 6-12 cm above the right coastal margin hence this finding is normal.
Choice B rationale: This finding is normal and does not indicate hepatomegaly.
Choice C rationale: Additional health history questions regarding alcohol intake may not be relevant in this case since the patient has a normal liver span.
Choice D rationale: The normal liver span in the midclavicular line is 6 to 12 cm, so an area of dullness of 11 cm above the right costal margin is within the normal range.
Correct Answer is A
Explanation
Choice A rationale: Severe bilateral lower extremity edema is commonly associated with heart failure. In heart failure, the heart's ability to pump blood is compromised, leading to fluid retention and peripheral edema.
Choice B rationale: Excess fluid retention is more of a symptom rather than an underlying cause. Heart failure is a condition that can lead to fluid retention.
Choice C rationale: Excess fluid consumption is unlikely to be the primary cause of severe bilateral lower extremity edema. Underlying medical conditions, such as heart failure, are more likely.
Choice D rationale: While a pulmonary embolism can lead to cardiovascular compromise, severe bilateral lower extremity edema is more commonly associated with heart failure.
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