Following a cerebrovascular accident (CVA), a client's prescriptions include neurologic assessments every 8 hours, and bedrest. The agency assessment tool includes evaluation of the client's posture. Which action should the nurse implement?

Assist the client to stand at the bedside long enough to observe posture.

Observe the client's ability to sit upright or unassisted while in the bed.

Document that posture could not be evaluated due to prescribed bedrest.

Ask the client to describe normal posture while walking and standing.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Assist the client to stand at the bedside long enough to observe posture: Assisting the client to stand would violate the bedrest order, which is in place to prevent complications such as increased intracranial pressure or falls following a CVA. Standing could pose unnecessary risks and is not appropriate when safer alternatives are available.

B. Observe the client's ability to sit upright or unassisted while in the bed: Evaluating posture can still be done safely within the constraints of bedrest by assessing how well the client can maintain an upright seated position. This allows the nurse to assess muscle tone, balance, and neurological function without compromising safety.

C. Document that posture could not be evaluated due to prescribed bedrest: Bedrest limits standing or walking, but it does not prevent all forms of posture evaluation. The nurse still has a responsibility to assess posture in ways that align with safety protocols and should not omit this part of the neurological assessment.

D. Ask the client to describe normal posture while walking and standing: Relying on the client's verbal report does not replace direct observation. Objective assessment is necessary for accurate neurological evaluation, especially in post-CVA clients where deficits in muscle control and balance may not be fully recognized by the client.

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Correct Answer is ["A","D","E"]

Explanation

Rationale:
A. Contracture: Contractures, which are the permanent tightening of muscles, tendons, or ligaments, can be identified visually through inspection. The nurse may notice abnormal positioning of joints or decreased range of motion, indicating underlying musculoskeletal abnormalities.

B. Crepitus: Crepitus refers to a crackling or grating sound felt or heard during joint movement and is best assessed through palpation or auscultation, not inspection. The nurse must touch or listen to the joint to detect crepitus, making it unsuitable for assessment by inspection alone.

C. Osteopenia: Osteopenia is a reduction in bone mineral density that is diagnosed through specialized imaging tests like dual-energy X-ray absorptiometry (DEXA) scans. It is not visible during physical inspection, as bone density changes do not produce obvious external signs without significant fractures.

D. Atrophy: Muscle atrophy, which is the wasting or loss of muscle mass, can be visually identified through inspection. The nurse may observe a noticeable decrease in muscle bulk compared to the opposite side or to expected norms, indicating disuse or neurologic impairment.

E. Kyphosis: Kyphosis, an exaggerated outward curvature of the thoracic spine, can be detected through inspection by observing the client’s posture and spinal alignment. Visual clues such as a hunchback appearance or forward stooping posture are hallmark signs noted during inspection.

A. Dim the lights in the examination room. B. Question the client about steroid use. C. Continue with the cardiac examination. D. Position the client in high Fowler's position.

Correct Answer is C

Explanation

Rationale:
A. Dim the lights in the examination room: Dimming the lights can sometimes help during inspection for certain assessments, such as using transillumination, but it does not assist in palpating or auscultating an apical pulse. Lighting conditions are unrelated to detecting heart sounds or movement.

B. Question the client about steroid use: While steroid use in body-builders can have cardiovascular implications, questioning about steroid use does not immediately address the challenge of locating an apical pulse. Investigating steroid use would be important later but not the priority action during the assessment.

C. Continue with the cardiac examination: In very muscular individuals, the apical impulse can be difficult to palpate due to increased chest wall thickness. It is appropriate to proceed with auscultation of heart sounds instead, as this method does not rely on palpating the apical impulse and still assesses cardiac function effectively.

D. Position the client in high Fowler's position: Changing the client's position to high Fowler’s can improve breathing and heart auscultation in some cases but does not specifically enhance palpation of the apical pulse in heavily muscled individuals. Continuing with auscultation without changing the position is the best immediate step.

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Following a cerebrovascular accident (CVA), a client's prescriptions include neurologic assessments every 8 hours, and bedrest. The agency assessment tool includes evaluation of the client's posture. Which action should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse begins a client's musculoskeletal assessment. While using the technique of inspection, the nurse assesses for which possible finding(s)? Select all that apply.

Correct Answer is ["A","D","E"]

Explanation

When assessing a 24-year-old body-builder, the nurse is unable to palpate an apical pulse. Which action should the nurse implement?

Correct Answer is C

Explanation

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