In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

Document the presence of nailbed clubbing.

Consult with a podiatrist to trim the client's toenails.

Determine the client's most recent hemoglobin level.

Administer a PRN prescription for oxygen.

Answer and Explanation

The Correct Answer is A

A.   Nailbed clubbing is characterized by an increased angle between the nail and the nailbed, typically greater than 180 degrees. An angle of 200 degrees is consistent with clubbing, which can be a sign of chronic respiratory or cardiovascular conditions, such as chronic lung diseases, congenital heart defects, or other systemic conditions.
B.   Consulting with a podiatrist to trim toenails is important for foot care but is not directly related to the finding of nailbed clubbing. The angle of the nailbed is more indicative of a systemic issue rather than a local foot care problem. Therefore, this action does not address the underlying concern suggested by the angle of 200 degrees.
C.   While anemia or other blood conditions can affect the nails, the specific finding of a nailbed angle of 200 degrees is more indicative of clubbing rather than issues typically associated with hemoglobin levels. Therefore, while monitoring hemoglobin is important for overall health, it is not the immediate priority in response to the finding of nailbed clubbing.
D.   Administering oxygen might be necessary if the client is experiencing symptoms of hypoxia or has a condition affecting oxygenation. However, the finding of nailbed clubbing itself does not immediately necessitate oxygen therapy. Oxygen administration should be based on specific symptoms or clinical indications of hypoxia rather than the nailbed angle alone.

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Correct Answer is A

Explanation

A. A mental status exam is a comprehensive assessment tool used to evaluate various aspects of cognitive function, including orientation, memory, attention, language, and higher cognitive functions. Given that the client is confused, a mental status exam is highly relevant to understand the scope of the confusion, identify possible underlying issues, and provide a baseline for further evaluation and treatment.
B. Eliciting a pain response is typically used to assess responsiveness in patients who are not fully conscious or are unresponsive. Since the client is described as alert and ambulatory, attempting to elicit a pain response is not the most appropriate next step. This action is more suited for assessing levels of consciousness in patients who are less responsive or in coma-like states.
C. The Babinski reflex is a neurological test where the sole of the foot is stroked to assess the presence of an abnormal reflex response. In adults, the presence of the Babinski reflex may indicate neurological damage. This test is more specialized and less relevant for a general assessment of confusion.
D. Assessing pupillary accommodation involves checking how well the pupils adjust to changes in light and focus. While this is an important part of a neurological assessment, it is not the most direct approach to addressing confusion. Pupillary responses are generally assessed alongside other neurological evaluations but do not specifically address the cognitive or confusion aspects of the mental status.

A. Gently press over each shin and measure indentation. B. Use a goniometer to measure and compare the legs. C. Compare the appearance of the legs bilaterally. D. Observe the client during heel-toe ambulation.

Correct Answer is C

Explanation

A. Pressing over the shins to measure indentation is a technique used to assess for edema, not muscle atrophy. Edema refers to fluid accumulation in the tissues, which can cause an indentation when pressed, whereas muscle atrophy involves a reduction in muscle mass and would not be detected by this method.
B. A goniometer is a tool used to measure the range of motion of joints, not muscle size. While it can be useful in assessing joint mobility and flexibility, it does not provide information about muscle mass or atrophy.
C. Comparing the appearance of the legs bilaterally is an appropriate method to assess for muscle atrophy. By visually inspecting and palpating both legs, the nurse can identify differences in muscle bulk and size. Muscle atrophy often presents as noticeable asymmetry between the two legs, with one leg appearing smaller or thinner compared to the other.
D. Observing the client during heel-toe ambulation can help assess gait and functional mobility, but it is not the most direct method for evaluating muscle atrophy. While gait abnormalities can suggest underlying muscle weakness or atrophy, direct visual and palpation comparison of muscle mass provides a clearer assessment of muscle atrophy.

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In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When assessing a client's level of consciousness, the nurse determines that the client is alert and ambulatory, but confused. Which follow- up assessment should the nurse complete next?

Correct Answer is A

Explanation

To assess for muscle atrophy in the legs, which action should the nurse take?

Correct Answer is C

Explanation

The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

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