A nurse is conducting a physical examination of the musculoskeletal system of a client who reports having joint pain. Which signs indicate there is inflammation in the joints? Select all that apply.

subcutaneous nodules

crepitus

warmth

swelling

redness

tenderness

Answer and Explanation

Correct Answer : C,D,E,F

A.   Subcutaneous nodules are lumps or masses that can occur beneath the skin, sometimes seen in conditions like rheumatoid arthritis.
B.   Crepitus refers to a crackling or popping sound heard or felt during joint movement. It is often associated with osteoarthritis or other joint conditions.
C.   Warmth or increased temperature over the joint area is a common sign of inflammation. It occurs because inflammation increases blood flow to the affected area.
D.   Swelling, or edema, is the accumulation of fluid in the joint space or surrounding tissues. It is a clear sign of inflammation and can be due to increased fluid production or leakage from blood vessels.
E.   Redness, or erythema, around the joint is a result of increased blood flow to the area due to inflammation. It is often accompanied by warmth.
F.   Tenderness refers to pain or discomfort in the joint area when touched or palpated. It indicates an inflammatory process in the joint.

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Correct Answer is A

Explanation

A. Decorticate rigidity is characterized by flexion of the arms and extension of the legs. In this posture, the upper arms are flexed and held tightly to the sides, with the elbows, wrists, and fingers also flexed. The legs are extended and internally rotated.
B. Flaccid posture, or flaccidity, is characterized by a complete lack of muscle tone, which leads to a limp and lifeless appearance. There is no resistance to passive movement, and the muscles are weak or paralyzed.

C. Decerebrate rigidity is characterized by extension of both the arms and the legs. In this posture, the arms are extended at the sides with the wrists and fingers flexed, and the legs are extended and internally rotated. This type of rigidity indicates damage to the brainstem below the red nucleus.
D. Hemiplegia refers to paralysis of one side of the body, which can result from brain injury or stroke affecting one hemisphere of the brain. The affected side will have limited or no movement and muscle tone.

A. Assess dilatation of pupils with direct light. B. Ask the client to differentiate between sharp and dull sensations on the client's face. C. Palpates temporal and masseter muscles while client clenches teeth. D. Have the client smile, frown, and wrinkle the forehead.

Correct Answer is C

Explanation

A. This test assesses the function of the oculomotor nerve (CN III), not the trigeminal nerve. The oculomotor nerve controls the constriction and dilation of the pupils, as well as some eye movements. Therefore, this choice is not appropriate for assessing the trigeminal nerve.
B. This test assesses the sensory function of the trigeminal nerve (CN V). The trigeminal nerve provides sensation to the face, and testing the ability to differentiate between sharp and dull sensations evaluates

the sensory component of this nerve. However, this test does not assess the motor function of the trigeminal nerve.
C. This test evaluates the motor function of the trigeminal nerve. The trigeminal nerve controls the muscles involved in chewing, including the temporal and masseter muscles. By palpating these muscles while the client clenches their teeth, the nurse assesses the strength and function of these muscles, which are innervated by the trigeminal nerve. This is a direct test of motor function for CN V.
D. This test assesses the function of the facial nerve (CN VII), which controls the muscles of facial expression. It is not relevant for assessing the trigeminal nerve, which is involved in both sensory functions of the face and motor functions related to chewing.

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A nurse is conducting a physical examination of the musculoskeletal system of a client who reports having joint pain. Which signs indicate there is inflammation in the joints? Select all that apply.

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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