A nurse assesses an audible grating sound (crepitus) when a client with osteoarthritis moves his knees. What is the cause of this sound?

Choice A reason: Color is a characteristic of exudate that should be included when documenting it. Color can indicate the type and severity of the wound infection or inflammation. For example, yellow or green exudate may indicate a bacterial infection, while red or brown exudate may indicate bleeding or necrosis.

Choice B reason: Odor is a characteristic of exudate that should be included when documenting it. Odor can indicate the presence and type of microorganisms in the wound. For example, a foul or putrid odor may indicate anaerobic bacteria, while a sweet or fruity odor may indicate pseudomonas.

Choice C reason: Heat is not a characteristic of exudate that should be included when documenting it. Heat is a sign of inflammation that can be assessed by palpating the skin around the wound, not by observing the exudate. Heat does not directly reflect the quality or quantity of the exudate.

Choice D reason: Consistency is a characteristic of exudate that should be included when documenting it. Consistency can indicate the viscosity and composition of the exudate. For example, thin or watery exudate may indicate a serous or serosanguineous fluid, while thick or creamy exudate may indicate a purulent or fibrinous fluid.

Choice E reason: Amount is a characteristic of exudate that should be included when documenting it. Amount can indicate the extent and stage of the wound healing process. For example, a large amount of exudate may indicate a high level of inflammation or infection, while a small amount of exudate may indicate a low level of inflammation or infection.

Choice A reason: This is the best intervention because it helps the nurse to understand the client's emotional, social, and practical needs and resources. A new diagnosis of HIV can be a devastating and overwhelming experience for the client, who may face stigma, discrimination, isolation, or rejection from others. The nurse should assess the client's support system, such as family, friends, or community groups, that can provide comfort, guidance, and assistance to the client. The nurse should also encourage the client to seek professional counseling, peer support, or other services as needed.

Choice B reason: This is not the best intervention because it may not respect the client's preferences, beliefs, or values. The nurse should not assume that the client wants or needs spiritual or religious support, unless the client expresses such a desire. The nurse should ask the client about their spiritual or religious beliefs and practices and provide appropriate referrals or resources as requested by the client. The nurse should also respect the client's right to privacy and confidentiality and not disclose the client's diagnosis to anyone without the client's consent.

Choice C reason: This is not the best intervention because it may not be the most urgent or appropriate topic to discuss with the client at this time. The nurse should not focus on the legal or ethical aspects of the client's diagnosis, but rather on the client's emotional and physical wellbeing. The nurse should explain the legal requirement to tell sex partners in a sensitive and respectful manner, but only after the client has accepted and understood their diagnosis and has expressed readiness to disclose their status to others. The nurse should also provide the client with information and resources on how to prevent the transmission of HIV and how to protect themselves and their partners.

Choice D reason: This is not the best intervention because it may not be the client's wish or choice. The nurse should not offer to tell the family for the client, unless the client asks for such help. The nurse should respect the client's autonomy and decisionmaking regarding whom to tell and when to tell about their diagnosis. The nurse should also support the client in preparing for the possible reactions and outcomes of disclosing their status to their family and others.