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) Information sharing is limited to those directly involved in the client's care: This statement reflects the principle of confidentiality and the ethical obligation to protect the client's private health information. Only healthcare providers directly involved in the client’s care should have access to their information, ensuring that it remains secure and confidential.

B) All members of the unit's healthcare team may have access to the client's chart: While many healthcare team members need access to the client's information for care coordination, this statement is misleading. Access should be limited to those directly involved in the client’s care to protect their confidentiality.

C) The Health Insurance Portability and Accountability Act (HIPAA) determines who may communicate with the client: While HIPAA does set guidelines for the protection of health information and governs the sharing of health data, it does not specifically determine who may communicate with the client. Instead, it focuses on protecting their privacy.

D) The medical records are open to any hospital employee, including administration: This statement is incorrect as it violates confidentiality principles. Medical records are not accessible to all hospital employees; access is restricted to authorized personnel only, ensuring that patient information is kept confidential.

A. Changes in peripheral vision in response to light B. Involuntary blinking in the presence of bright light C. Pupillary dilation when looking at a near object D. Pupillary constriction when looking at a near object

Correct Answer is D

Explanation

A) Changes in peripheral vision in response to light: While peripheral vision is important in a comprehensive eye assessment, it is not specifically evaluated through the PERRLA acronym. PERRLA focuses on how the pupils respond to light and accommodation, not on peripheral vision changes.

B) Involuntary blinking in the presence of bright light: Involuntary blinking is part of a reflex action known as the blink reflex, which helps protect the eyes from bright lights and foreign objects. However, this response is not what the "A" in PERRLA refers to, which is more specifically about pupillary reactions to focus.

C) Pupillary dilation when looking at a near object: When focusing on a near object, the pupils actually constrict rather than dilate. This process, known as accommodation, is important for clear vision at close distances but does not pertain to the dilation of pupils.

D) Pupillary constriction when looking at a near object: The "A" in PERRLA stands for accommodation, which specifically refers to the pupils constricting when a person looks at a nearby object. This reaction helps the eyes focus properly and is a normal finding in a healthy neurological assessment. Thus, option D accurately describes the "A" in the PERRLA assessment.

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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?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is D

Explanation

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