A client states, "I can hear a crunching or grating sound when I kneel and have difficulty getting out of 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

Answer and Explanation

The Correct Answer is B

A.   A bone spur is a bony projection often caused by joint damage, but it does not typically produce audible crunching or grating sounds.
B.   Crepitation refers to a crunching, grating, or popping sound or sensation that occurs with movement of a joint. It's often associated with conditions like osteoarthritis.
C.   Tendonitis involves inflammation of a tendon and may cause pain or tenderness, but it does not typically produce audible sounds like crepitation.
D.   Fluid in the knee joint might cause swelling and limited movement, but it does not usually produce audible crunching or grating sounds.

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Correct Answer is B

Explanation

A. A capillary refill of less than 5 seconds is considered normal.
B. Radial pulses 2+ with regular rate and rhythm bilaterally indicate good peripheral circulation.
C. Feet that are pale and cool to the touch could indicate decreased perfusion or vascular compromise.
D. Right ankle 1+ edema may suggest some fluid retention but no perceptible swelling of the leg indicates relatively normal findings in that area.

A. Very deep pitting indentation of legs lasts several minutes. B. Deep pitting indentation of legs lasts a few minutes. C. Mild pitting, no perceptible swelling of the legs. D. Moderate pitting: indentation of legs subsides rapidly.

Correct Answer is A

Explanation

A. 4+ edema is characterized by very deep pitting, where the indentation remains for an extended period (several minutes), indicating severe fluid accumulation in the tissue.
B. Deep pitting that lasts for a few minutes is more consistent with 2+ or 3+ edema, not the severe 4+ edema described.
C. Mild pitting with no perceptible swelling does not align with 4+ edema; this level of pitting suggests minimal fluid accumulation.
D. Moderate pitting where the indentation subsides rapidly is indicative of 2+ edema, not the profound swelling described as 4+ edema.

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A client states, "I can hear a crunching or grating sound when I kneel and have difficulty getting out of bed in the morning because of pain and stiffness." Which of the following should the nurse expect as an assessment finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse has completed a peripheral vascular assessment on a client. Which of the following would the nurse document as expected findings?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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