A nurse is collecting data from a client who has osteoarthritis of the knee.
Which of the following assessment findings should the nurse expect?
Malaise.
Weakness.
Fever.
Crepitus.
The Correct Answer is D
Choice A rationale
Malaise is a general feeling of discomfort or illness that is more commonly associated with systemic inflammatory conditions like rheumatoid arthritis rather than the localized wear-and-tear of osteoarthritis. Osteoarthritis is a degenerative joint disease characterized by the breakdown of articular cartilage. Since it is not a systemic autoimmune disease, patients typically do not experience the generalized exhaustion or constitutional symptoms that are hallmarks of inflammatory arthritis types that affect the whole body.
Choice B rationale
While muscle weakness can occur secondary to disuse of a painful joint, it is not a primary diagnostic finding expected specifically for osteoarthritis of the knee. Weakness is often a late-stage consequence of the patient limiting their activity to avoid pain. The nurse focuses on joint-specific symptoms during the assessment. In osteoarthritis, the pathology is centered on the joint space narrowing and bone spur formation, rather than a primary neuromuscular deficit or an acute muscle pathology.
Choice C rationale
Fever is a systemic sign of inflammation or infection and is not a characteristic finding in osteoarthritis. Osteoarthritis is considered a non-inflammatory joint disease, although mild localized swelling can occur. The presence of a fever would instead suggest a septic joint, gout, or a systemic inflammatory disease like rheumatoid arthritis. In a standard case of knee osteoarthritis, the nurse would expect the skin over the joint to be cool and the patient to be afebrile.
Choice D rationale
Crepitus is a classic assessment finding in osteoarthritis, characterized by a grating or popping sensation felt or heard during joint movement. This occurs because the protective cartilage has worn away, causing the irregular bone surfaces to rub against each other. It is a direct result of joint space narrowing and the presence of osteophytes. Identifying crepitus helps the nurse confirm the mechanical degradation of the knee joint, which is the primary pathological process in this degenerative condition.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Applying heat to an acute surgical site following hip arthroplasty is generally contraindicated because heat causes vasodilation, which can increase localized edema and potentially lead to surgical site bleeding. While heat may alleviate chronic muscle stiffness, it does not directly support tissue integrity in the immediate postoperative phase. Standard protocols usually favor cryotherapy to reduce metabolic demand and inflammation, which helps protect the surgical incision and the surrounding soft tissue during the initial healing process.
Choice B rationale
While preventing constipation is a common postoperative goal to avoid strain, administering laxatives is not the most essential intervention specifically for maintaining the integrity of the surgical skin and deep tissues. Bowel management supports general comfort and systemic health but does not directly influence the mechanical or vascular stability of the hip incision. Tissue integrity after arthroplasty relies more heavily on physical positioning and pressure relief to ensure adequate perfusion and prevent the formation of pressure ulcers.
Choice C rationale
Switching positions frequently is essential for maintaining tissue integrity because it prevents prolonged pressure on bony prominences, which can lead to localized ischemia and pressure injuries. In the postoperative hip patient, repositioning must be done carefully to maintain hip precautions, but it ensures that blood flow remains consistent to the skin and subcutaneous layers. Constant movement or scheduled turning reduces the risk of skin breakdown, which is a critical complication that can compromise the surgical outcome.
Choice D rationale
Guided meditation is a beneficial psychosocial intervention for pain management and stress reduction, but it lacks a direct physiological impact on the mechanical integrity of the surgical site. While it may lower systemic cortisol levels and promote a healing environment, it cannot replace physical interventions like repositioning or wound care. Tissue integrity requires physical strategies to manage pressure, moisture, and friction, which meditation alone cannot address in a patient who has undergone a major orthopedic procedure.
Correct Answer is A
Explanation
Choice A rationale
Tissue injury represents a breach in the primary defense mechanism of the body and can lead to localized or systemic infection. Prioritizing the evaluation of the injury allows the nurse to identify signs of necrosis, purulence, or cellulitis that could be the source of the low grade fever. Tissue integrity is fundamental to preventing sepsis. Monitoring for complications such as compartment syndrome or gangrene is more critical than treating a mild temperature elevation that may be a normal inflammatory response.
Choice B rationale
Hydration is important for maintaining perfusion to injured tissues and supporting metabolic processes during healing. However, it is a supportive measure rather than a primary diagnostic priority. While fluid loss can occur through large wounds, a low grade fever alone does not usually indicate a severe fluid volume deficit. The nurse must first understand the nature and severity of the tissue injury to determine the appropriate rate and type of fluid resuscitation required for the client.
Choice C rationale
Requesting labs is a collaborative intervention that provides objective data on the inflammatory response and potential infection. While hematology profiles like White Blood Cell counts are useful, the physical assessment of the tissue injury provides more immediate information regarding the localized state of the wound. Labs confirm what the physical assessment suggests. The nurse should prioritize the direct inspection of the site to guide the urgency of laboratory testing and other medical orders.
Choice D rationale
A low grade fever is often a beneficial physiological response that enhances immune function and inhibits pathogen replication. Treating it immediately with antipyretics can mask the clinical progression of an underlying infection. Fever is a symptom, not the primary pathology. The focus should remain on identifying and managing the cause of the fever, which in this case is likely the tissue injury. Antipyretics should be reserved for higher temperatures or when the client experiences significant discomfort.
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