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 A
Explanation
A. Ask the client to describe the pain: This is the most crucial step. A good pain description can reveal characteristics like intensity, location, duration, and aggravating/relieving factors, all aiding in diagnosis.
B. Observe body language and movement: Nonverbal cues like grimacing, guarding (tensing muscles), or restlessness can indicate pain severity or location.
C. Identify effective pain relief measures: While this might be helpful later, it's not the primary way to assess pain quality initially.
D. Provide a numeric pain scale: Pain scales can be helpful for quantifying pain intensity, but a full description provides richer details.
Correct Answer is B
Explanation
A. Explain to the client the possible causes of dyspnea or "shortness of breath.": While the nurse might eventually explain this, it's premature without more information about the client's specific shortness of breath experience.
B. Ask the client to describe the episodes of dyspnea in more detail: This is the most appropriate next step. Understanding the characteristics, triggers, and severity of the dyspnea will help determine the cause and guide further assessment.
C. Document "dyspnea on exertion" in the client's medical record: The client only reports experiencing shortness of breath "at times," not necessarily with exertion. More details are needed before documenting.
D. Ask the client to perform light exercise and observe the respiratory effort: This could worsen the client's condition if the shortness of breath is severe. Observation during rest provides a safer approach initially.
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