The nurse is planning to determine whether a patient has fluid in ...

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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

Question 2

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.

[angrybirds13579]

Answer to Question 1

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.

Answer to Question 2

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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TYSM

[amit]

Excellent