While conducting range of motion with an older patient, the patient begins to cry and states, "My knee hurts when you do that!" Which interventions should be implemented at this time?
Select all that apply.
1. Continue with the assessment.
2. Stop ROM immediately in that extremity.
3. Massage the knee for 20 minutes.
4. Call the physician.
5. Have the patient complete the assessment alone.
Correct Answer: 2, 4
ROM should be performed without causing the patient discomfort. Knee pain may be referred pain from a hip fracture or other hip injury as well as alteration in the structure of the knee. The action should be stopped. The physician may order diagnostic tests in order to evaluate the source of the pain. Massaging the knee may cause further pain and discomfort to the patient and has no therapeutic benefit at this time. Do not cause further injury by continuing with the assessment.
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The client and her partner are carriers of sickle-cell disease. They are considering prenatal diagnosis with either amniocentesis or chorionic villus sampling (CVS)
Which statements indicate that further teaching is needed on these two diagnostic procedures? Select all that apply. 1. "Chorionic villus sampling carries a lower risk of miscarriage." 2. "Amniocentesis can be done earlier in my pregnancy than CVS." 3. "Neither test will conclusively diagnose sickle-cell disease in our baby." 4. "The diagnosis comes sooner if we have CVS, not amniocentesis." 5. "Amniocentesis is more accurate in diagnosis than the CVS."
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What will be an ideal response?
Confidentiality will be maintained by a nurse who believes in and values the ethical principle of:
a. Fidelity b. Veracity c. Beneficence d. Autonomy
When the nurse is alone with a battered patient, the patient seems extremely anxious and says, "It was all my fault. The house was so messy when he got home and I know he hates that." The best response by the nurse is:
a. "No one deserves to be hurt. It's not your fault. How can I help you?" b. "What else do you do that makes him angry enough to hurt you?" c. "He will never find out what we talk about. Don't worry. We're here to help you." d. "You have to remember that he is frustrated and angry so he takes it out on you."