The nurse is planning to determine whether a patient has fluid in the knee. What should the nurse use to make this assessment?
Select all that apply.
1. ballottement
2. bulge sign
3. Phalen's test
4. Thomas test
5. McMurray test
Correct Answer: 1, 2
To assess for larger amounts of fluid in the knee, the nurse should conduct the ballottement test, which is done by applying downward pressure on the knee with one hand while pushing the patella backward against the femur with the other hand. There should be no movement of the patella. The patella should rest firmly over the femur. Increased fluid will cause a tapping sound as the patella displaces the fluid and hits the femur. Bulge sign indicates increased fluid in the knee joint and is indicated to assess for smaller amounts of fluid on the knee. Phalen's test is an assessment tool that may be indicative of carpal tunnel syndrome. The Thomas test may indicate hip contracture. The McMurray test is used to indicate an injury to a meniscus, a disk of cartilaginous tissue in the knee.
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