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. A hallucination is a sensory experience that occurs without any external stimulus. It involves perceiving things that are not present in the environment, such as hearing voices or seeing things that are not there. The young man hearing his deceased sister talking to him in his head is an example of an auditory hallucination, which is a common symptom in schizophrenia.
B. Perseveration is the repetitive and persistent repetition of a particular response, such as a word or action, despite the absence of a stimulus or the problem being resolved. It is not related to abnormal sensory perceptions but rather to repetitive behaviors or speech. The young man's experience of hearing voices does not fit this description.
C. A fugue state is a type of dissociative disorder where a person suddenly and unexpectedly travels away from home or customary work locations and cannot recall their past. It often involves amnesia for personal history. The scenario described does not involve such travel or amnesia but rather auditory experiences, making this term irrelevant.
D. An illusion is a misperception of an actual external stimulus. It involves incorrectly interpreting a real sensory input, such as mistaking a shadow for a person. Since the young man is not misinterpreting a real external stimulus but rather hearing something that is not present at all, an illusion does not accurately describe his experience.

A. Verbal respond B. Motor respond C. Pupillary responds D. Gag Reflex E. Eye Opening

Correct Answer is ["A","B"]

Explanation

A. The verbal response is one of the three components of the Glasgow Coma Scale. It assesses the patient's ability to speak and respond appropriately to questions, indicating their level of consciousness. Responses are scored based on clarity, coherence, and relevance.
B. Motor response is another component of the Glasgow Coma Scale. It evaluates the patient’s ability to move in response to stimuli, including purposeful movements, localizing pain, or abnormal posturing. The motor response helps gauge the patient’s level of consciousness and neurological function.
C. Pupillary response refers to how the pupils react to light and changes in size. While important in neurological assessments, it is not one of the three components of the Glasgow Coma Scale. Pupillary response is assessed separately from the GCS but provides additional information about brain function and potential injury.
D. The gag reflex is a protective mechanism to prevent choking and is assessed by stimulating the back of the throat. It is not included in the Glasgow Coma Scale. The GCS focuses on eye opening, verbal response, and motor response rather than reflexes.
E. Eye opening is the third component of the Glasgow Coma Scale. It assesses the patient’s ability to open their eyes spontaneously or in response to stimuli. This component helps determine the level of consciousness and alertness.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

Which are the 3 areas included in the Glasgow Coma Scale to assess levels of consciousness? Select all that Apply.

Correct Answer is ["A","B"]

Explanation

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