In assessing an older adult client, the nurse notes that the client's right arm muscles feel soft and boggy. To gather additional data related to this finding, which assessment should the nurse complete next?
Determine degree of skin elasticity.
Measure muscle size and strength.
Inspect appearance of the spine.
Note 24-hour fluid intake and output.
The Correct Answer is B
A. Determine degree of skin elasticity: While decreased skin elasticity can be a sign of aging, it doesn't directly assess muscle tone or strength.
B. Measure muscle strength: This is the most appropriate next step to confirm the nurse's initial suspicion of weak muscles. Techniques like manual muscle testing can assess muscle strength.
C. Inspect appearance of the spine: Spinal issues can affect movement and coordination, but they wouldn't necessarily explain soft and boggy muscles in one arm.
D. Note 24-hour fluid intake and output: This might be relevant for overall health assessment but doesn't directly assess muscle tone or strength.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Use an interpreter throughout the client's hospitalization. Consistently using an interpreter throughout the client's hospitalization ensures clear communication, improves understanding, and enhances the quality of care. However, this answer does not address the specific context of the health assessment interview.
B. Maintain eye contact with client when questions are asked. Maintaining eye contact with the client rather than the interpreter helps build rapport and shows respect and engagement with the client. This practice encourages the client to feel directly involved in the conversation, even though an interpreter is present, fostering a sense of trust and comfort.
C. Ask the interpreter to tell the client to write down questions. This option may be less effective if the client has limited literacy or is uncomfortable with writing. Additionally, it adds an unnecessary step that can complicate the communication process.
D. Give the interpreter a form that lists the interview questions. Providing the interpreter with a list of questions might help streamline the process but can depersonalize the interaction and reduce the engagement with the client. It is more effective for the nurse to ask questions directly and maintain communication with the client.
Correct Answer is B
Explanation
A. "I am sorry you feel that way. Perhaps you'd like to return when you have more time."
While this response acknowledges the client's feelings, it may inadvertently dismiss the client's concerns and fail to address the immediate need for treatment. It's important for the nurse to engage with the client and explore their concerns rather than suggesting they come back later.
B. "You sound angry. Would you like to tell me about it?"
This response demonstrates empathy and acknowledges the client's emotions. By inviting the client to express their feelings further, the nurse opens the door for communication and understanding. It allows the nurse to explore the underlying reasons for the client's frustration and address their concerns.
C. Ignore the angry outburst and continue with the history questions.
Ignoring the client's emotional outburst may cause the client to feel unheard or invalidated, potentially escalating the situation further. It's essential for the nurse to address the client's concerns and emotions to maintain a therapeutic relationship and provide effective care.
D. Move closer and place a hand on the client's shoulder to demonstrate concern.
While physical touch can be comforting for some individuals, it's important to consider the client's preferences and boundaries, especially in a situation where the client is expressing frustration or impatience. Approaching the client physically without consent may not be appropriate and could further exacerbate the situation.
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