The nurse assesses a client and finds that a grating sound is present when a joint is bent and straightened. Which term will the nurse use when documenting this finding in the medical record?

Crepitus

Positive joint sounds

Grating and popping

Crackles

Answer and Explanation

The Correct Answer is A

A) Crepitus: This is the correct term to document the grating sound heard when a joint is moved. Crepitus can indicate issues such as the presence of air in the joint, cartilage degeneration, or other pathologies. Using this specific term provides clarity to the medical record and helps other healthcare providers understand the nature of the joint's condition.

B) Positive joint sounds: This phrase is less specific and does not adequately describe the type of sound noted during the assessment. It may also lead to ambiguity, as it lacks the medical precision that crepitus provides.

C) Grating and popping: While this description conveys what the nurse observed, it is not a standardized medical term. Precise documentation is essential in medical records, and using non-standard language can lead to confusion.

D) Crackles: Typically associated with respiratory assessments, crackles refer to sounds heard in the lungs and are not applicable to joint examinations. Therefore, this term would be inappropriate for documenting findings related to joint movement.

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Correct Answer is A

Explanation

A) Stiff neck and shoulder pain: This symptom is very common in clients with a herniated cervical disc. The herniation can lead to irritation or compression of nearby nerves, resulting in localized pain in the neck and shoulder region. Clients often report this discomfort as one of their primary concerns.

B) Cauda equina syndrome: This serious condition arises from compression of the cauda equina, which occurs in the lower lumbar region of the spine, not the cervical area. Therefore, it is not a typical symptom of a cervical disc herniation.

C) Changes in knee and ankle reflexes: These changes are more associated with lumbar spine issues. While cervical disc problems can affect reflexes, they typically do not present as changes in lower limb reflexes, which are primarily linked to lower back conditions.

D) Sciatica: This term usually refers to pain that radiates down the leg due to compression of the sciatic nerve, often associated with lumbar disc herniation. It is not a common symptom of cervical disc herniation, which affects the neck and upper extremities.

A. To determine the location of the pain. B. To establish the effectiveness of medication. C. To make changes to the patient's pain goal. D. To measure the pain's duration.

Correct Answer is B

Explanation

A) To determine the location of the pain: While knowing the location of the pain can be relevant for overall assessment, this is not the main reason for reassessing pain after treatment. The focus is more on understanding the response to treatment rather than just identifying where the pain is.

B) To establish the effectiveness of medication: Reassessing pain after treatment is essential to evaluate how well the medication has alleviated the pain. This helps the nurse determine if the current pain management approach is effective or if modifications are necessary to improve the patient's comfort.

C) To make changes to the patient's pain goal: While understanding pain levels can inform care planning, the primary purpose of reassessing pain is to gauge treatment effectiveness rather than directly changing the pain management goals at that moment.

D) To measure the pain's duration: Measuring the duration of pain may be useful in a broader context of pain management, but it is not the immediate rationale for reassessing pain after treatment. The focus should be on the effectiveness of the intervention rather than just how long the pain lasts.

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The nurse assesses a client and finds that a grating sound is present when a joint is bent and straightened. Which term will the nurse use when documenting this finding in the medical record?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which condition or symptom is most common in clients with a herniated cervical disc?

Correct Answer is A

Explanation

Which of the following is the rationale for the nurse to reassess the patient's pain after treatment?

Correct Answer is B

Explanation

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