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.
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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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Cloudy discharge is more commonly associated with infections or discharge from the genital area rather than residual urinary symptoms. While urinary tract infections (UTIs) can cause cloudy urine, this is not typically associated with suprapubic tenderness or the sensation of residual pressure alone.
B. An overactive bladder is characterized by symptoms such as frequent urination, urgency, and sometimes incontinence. However, it does not typically cause suprapubic tenderness or a sensation of residual pressure after urination. The described symptoms are more consistent with bladder outlet obstruction or incomplete bladder emptying rather than an overactive bladder.
C. Black tarry stools indicate upper gastrointestinal bleeding and are unrelated to urinary symptoms. This finding would suggest a different issue entirely, such as gastrointestinal bleeding, rather than a problem with the urinary tract or bladder. This is not consistent with the client's reported symptoms of suprapubic tenderness and sensation of residual pressure after urination.
D. A weak urinary stream is a common symptom associated with bladder outlet obstruction or conditions affecting urinary flow, such as benign prostatic hyperplasia (BPH) in older men. This finding aligns with the client's reported symptoms of suprapubic tenderness and feeling of residual pressure after urination.
Correct Answer is D
Explanation
A. Vellus hair is fine, short, and lightly pigmented hair that covers most of the body. It is not typically associated with the effects of hair dye or chemical treatments. Excess vellus hair would be unusual in this context and is not related to the typical outcomes of hair dyeing.
B. Fine, thin, and limp hair can be a result of chemical damage from hair dyeing and other treatments. Hair that has been subjected to frequent dyeing and chemical processing can lose its strength and texture, becoming weaker and less resilient. This finding is consistent with the impact of repeated hair dyeing.
C. A receding front hairline is typically associated with genetic factors and androgenic alopecia (pattern baldness) rather than the effects of hair dyeing. Although hair loss can be influenced by various factors, including chemicals, a receding hairline is not a direct consequence of dyeing hair.
D. Coarse, dry, and brittle hair is a common result of frequent chemical treatments, including hair dyeing. Chemicals in hair dyes can strip moisture from the hair, leading to a rough texture, breakage, and brittleness. This finding is consistent with long-term use of hair dye and chemical processing.
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