The nurse assesses a client and finds that a grating sound is present when a joint is bent and straightened. The nurse would correctly document this finding as which of the following?
1. Subluxation
2. Grinding
3. Crepitation
4. Joint dislocation
3
Rationale 1: Subluxation refers to a partial joint location.
Rationale 2: Grinding sounds may be heard or felt with musculoskeletal disorders but it is not appropriate medical terminology.
Rationale 3: Crepitation is the medical term used to describe the grating sounds a joint makes when the articulating surfaces have lost their cushioning cartilage.
Rationale 4: There is inadequate information to determine the joint is indeed dislocated.
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A hospice nurse is caring for a variety of clients who are dying. Which end-of-life and death ritual is paired with the correct religion?
a. Roman Catholic - Autopsies are not allowed except under special circumstances. b. Christian - Upon death, a religious leader should perform rituals of bathing and wrapping the body in cloth. c. Judaism - A person who is extremely ill and dying should not be left alone. d. Islam - An ill or dying person should receive the Sacrament of the Sick.
A client has come to the clinic for an annual physical and asks the nurse for an immunization against HIV. The best response by the nurse would be:
1. "I'll ask the physician to write an order for the immunization." 2. "Immunization against HIV is being investigated, but is not yet a reality." 3. "Where did you hear about that?" 4. "Why do you think you need a shot for HIV?"
A nurse is caring for a client who is 14 years old. At this developmental stage, this client's fearfulness would most likely be related to which condition?
A) Loud noises B) Strangers and darkness C) Death D) Social rejection
In selecting an activity to help develop the developmental task of industry for a school-age child who is hospitalized with a broken leg, the nurse would select:
a. A comic book to be read quietly b. A video game for distraction c. A competitive board game with another child d. A coloring book to enhance creativity