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 ability to swallow pureed foods is not an immediate concern and does not indicate a life-threatening condition.
Choice B rationale: Mild headache, while noteworthy, may not require immediate attention unless it is accompanied by other concerning symptoms.
Choice C rationale: Weakness is a general symptom that should be further assessed for severity and associated symptoms before determining the urgency of intervention. The GCS score of 5 takes precedence in this context.
Choice D rationale: A Glasgow Coma Scale (GCS) of 5 indicates severe impairment of consciousness and requires immediate attention. A lower GCS score reflects a deeper level of coma.
Correct Answer is D
Explanation
Choice A rationale: Paralysis refers to the loss of muscle function and is not consistent with burning or tingling sensations.
Choice B rationale: Hemiparesis refers to weakness on one side of the body and is not specific to abnormal sensations in the extremities.
Choice C rationale: Paraphasia refers to language disturbances and is not related to the described abnormal sensations in the extremities.
Choice D rationale: Abnormal sensations of burning or tingling in the extremities are indicative of paresthesia. Paresthesia refers to abnormal sensations, such as tingling or prickling, often associated with nerve dysfunction.
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