Answer to Question 1
Correct Answer: 1, 2, 3, 4
The assessment of a client presenting with an injury to the knee would include inspection, palpation, bulge sign testing, and ballottement. The nurse would visually inspect the knee's general appearance, including the presence or redness, swelling and dislocation. The knee's appearance would be contrasted with the unaffected knee. The area would be palpated for tenderness and warmth. The bulge sign test is used to detect the presence of small amounts of fluid (4 to 8 ml) in the suprapatellar bursa. The test involves placing the client in the supine position and then using firm pressure to stroke the medial aspect of the knee upward several times, displacing any fluid. As the pressure is applied to the lateral side of the knee the medial side is observed for bulging. Ballottement is a technique used to detect fluid, or to examine or detect floating body structures. The nurse displaces body fluid and then palpates the return impact of the body structure. Percussion is the use of tapping actions by the examiner. This tapping elicits sounds that can be evaluated for tone and depth to detect the presence of abnormalities. Percussion is normally utilized to assess the lungs and abdominal cavity. It is not used to assess for knee injuries.
Answer to Question 2
Correct Answer: 2
Proper placement and monitoring of an automatic blood pressure cuff will reduce the risk of injury o
The nurse uses a noninvasive bladder ultrasound to measure the client’s bladder volume.
Place a towel or sheet over knee area. Use a thin barrier to protect skin from cold source.
Using small, circular strokes, exfoliate the client’s neck and back.
Measuring the client’s height with a platform scale
Testing client’s ability to identify sharp sensations