During the admission assessment, the nurse observes that a client has a limping gait. Which assessment should the nurse complete next?

Ask about pain while bearing weight.

Determine level of consciousness.

Observe for deformity of the spine.

Measure orthostatic blood pressure.

Answer and Explanation

The Correct Answer is A

A.   A limping gait can be a sign of pain or discomfort while walking. By asking about pain while bearing weight, the nurse can get a better understanding of the underlying cause of the limp.
B.   A limping gait is not typically associated with changes in level of consciousness. This assessment is not relevant in this situation.

C.   While a spinal deformity can cause a limping gait, it is not the most likely cause in this case. The nurse should first assess for pain while bearing weight to get a better understanding of the underlying issue.
D.   Orthostatic blood pressure is a measure of blood pressure changes when a person stands up. It is not typically associated with a limping gait and is not relevant in this situation.

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Correct Answer is C

Explanation

A. Being oriented x 3 means the client is aware of their name, the current time (or day), and the location (place). In this case, since the client is only able to remember his name and where he is, but not the time, day, or date, this documentation would be incorrect. The client does not meet the criteria for being oriented x 3.
B. Being oriented x 1 means the client is aware of only one aspect of orientation, such as their name. Since the client is able to remember both his name and his location, documenting as oriented x 1 would not fully capture the extent of the client's orientation. The client is oriented to more than one aspect.
C. Being oriented x 2 means the client is aware of two aspects of orientation. In this case, since the client is able to remember his name and his location (but not the time, day, or date), documenting as oriented x 2 accurately reflects his level of orientation.
D. Being oriented x 4 means the client is aware of four aspects: their name, the current time (or day), the date, and the location. Given that the client can only remember his name and location, this
documentation would be incorrect as it does not align with the client’s current state of orientation.

A. Hyperactive bowel sounds are present in all quadrants. B. Small frequent meals cause heartburn to worsen. C. Heartburn occurs when lying down at night. D. Bowel movements are light grey and chalky.

Correct Answer is C

Explanation

A. Hyperactive bowel sounds are not typically associated with gastroesophageal reflux disease (GERD). They are more indicative of gastrointestinal disturbances such as increased bowel activity or a bowel obstruction. Since the client's symptoms are related to heartburn, assessing bowel sounds is less relevant to GERD. This choice does not provide useful information for diagnosing or managing GERD.
B. This option is not commonly associated with GERD. In fact, small frequent meals are often recommended as a management strategy for GERD to reduce the occurrence of heartburn, as large meals can exacerbate symptoms by increasing stomach pressure. This choice does not align with typical GERD management strategies and may not be a useful symptom to assess in this context.
C. This finding is highly relevant for GERD. Heartburn that occurs or worsens when lying down, especially at night, is a classic symptom of gastroesophageal reflux disease. When a person lies flat, stomach acid can more easily flow back into the esophagus due to decreased gravitational pressure, leading to heartburn. Identifying this symptom helps confirm GERD and guides management strategies, such as elevating the head while sleeping or avoiding late meals.
D. Light grey and chalky stools are indicative of issues related to bile production and could suggest a problem with the liver or biliary system rather than GERD. This symptom is not associated with GERD and would be more relevant in assessing conditions such as biliary obstruction or liver disease.

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During the admission assessment, the nurse observes that a client has a limping gait. Which assessment should the nurse complete next?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

Correct Answer is C

Explanation

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