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 C
Explanation
A) Anterior to the elbow: This term describes a location in front of the elbow. While it indicates a direction, it does not specifically address the vertical relationship of the discomfort in relation to the elbow. Since the client described discomfort "above" the elbow, this term is not the most accurate choice.
B) Distal to the elbow: The term "distal" refers to a location that is farther away from the trunk of the body or point of reference. Given that the discomfort is described as being above the elbow, this term is incorrect, as it would imply the discomfort is located toward the hand rather than toward the shoulder.
C) Proximal to the elbow: This term correctly indicates a location closer to the trunk of the body and specifically suggests that the discomfort is situated above the elbow, making it the most appropriate medical terminology to use in this context. It accurately reflects the relationship of the discomfort to the elbow.
D) Inferior to the elbow: "Inferior" refers to a location below another point of reference. Since the discomfort is described as above the elbow, this terminology would not apply and would misrepresent the location of the client’s discomfort.
Correct Answer is C
Explanation
A) Motor component of IV (Trochlear): The trochlear nerve primarily controls the superior oblique muscle of the eye, which is responsible for downward and lateral eye movements. The findings described do not relate to eye movement and therefore do not indicate dysfunction of this nerve.
B) Motor and sensory components of XI (Accessory): The accessory nerve innervates the sternocleidomastoid and trapezius muscles, primarily affecting head rotation and shoulder elevation. The symptoms noted in the assessment do not pertain to these muscle functions, so this option is not correct.
C) Motor component of VII (Facial): The signs of asymmetry in frowning, uneven eyebrow lifting, sagging eyelids, and air escaping when puffing the cheeks are characteristic of dysfunction in the facial nerve (cranial nerve VII). This nerve controls the muscles of facial expression, and impairment would lead to the described asymmetrical movements.
D) Motor component of X (Vagus) and sensory component of XII (Hypoglossal): The vagus nerve affects autonomic functions and some swallowing muscles, while the hypoglossal nerve controls tongue movements. Neither nerve is primarily responsible for the facial expressions described in the assessment findings, making this option incorrect.