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
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","B","C"]
Explanation
A) Blood pressure 150/90: This data is objective because it is a measurable value obtained through direct observation using a sphygmomanometer. It provides a quantifiable assessment of the client's cardiovascular status and can be verified by others, making it an important piece of objective data.
B) Bowel sounds present in all 4 quadrants: The assessment of bowel sounds is objective as it involves physical examination techniques that can be observed and documented by the nurse. The presence of bowel sounds indicates gastrointestinal activity, and this finding can be consistently assessed across different healthcare providers.
C) PERRLA: The abbreviation stands for "Pupils Equal, Round, Reactive to Light and Accommodation." This assessment is objective as it involves specific, observable measurements of the client's pupils during an eye examination. It can be consistently evaluated by different healthcare professionals, ensuring reliable documentation.
D) Anxious about surgical procedure: This statement is subjective as it reflects the client's personal feelings and emotional state. While important for understanding the client's experience, it cannot be measured or observed directly by the nurse and relies on the client's self-reporting.
E) Dyspnea on exertion: While dyspnea can be observed, the phrase "on exertion" refers to the client's subjective experience of breathlessness. Although it can be assessed through observation of respiratory patterns, the experience itself is based on the client's interpretation, making it subjective data.
Correct Answer is A
Explanation
A) Barrel Chest: This term describes a condition where the anterior-posterior (AP) diameter of the chest is equal to the transverse diameter, giving the chest a rounded appearance. This finding is often observed in older adults or individuals with chronic respiratory conditions, and it indicates a potential increase in lung volume and air trapping, commonly seen in conditions like emphysema or chronic obstructive pulmonary disease (COPD).
B) Chronic Obstructive Pulmonary Disease: While barrel chest can be associated with COPD, it is not a direct descriptor of the chest shape. COPD encompasses various symptoms and physiological changes but does not specifically define the chest's physical appearance as barrel-shaped.
C) Anterior/Posterior Distortion: This term does not accurately describe the findings observed in the assessment. While it suggests some alteration in chest shape, it does not specifically refer to the characteristic appearance of barrel chest, which is a well-defined clinical term.
D) Lordosis: This refers to an excessive inward curve of the spine, particularly in the lumbar region. While it may affect posture and overall body alignment, it does not relate to the chest shape or measurements, making it an inappropriate choice in this context.