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.

Answer and Explanation

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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Deep, continuous pain in the calf muscles. This symptom is more indicative of deep vein thrombosis (DVT) rather than venous insufficiency.

B. Painful symptoms alleviated by warmth. This symptom is not typically associated with venous insufficiency; it may be seen in conditions like arthritis.

C. Cool, pale skin below the knees. This finding is more suggestive of arterial insufficiency rather than venous insufficiency.

D. Decreased pain when legs are elevated. Venous insufficiency is characterized by impaired blood flow in the veins, leading to symptoms such as leg aching, tiredness, swelling, and skin changes like leathery appearance. Elevating the legs can help alleviate symptoms of venous insufficiency by reducing venous pressure and improving blood flow back to the heart. Therefore, a subjective finding indicating decreased pain when the legs are elevated suggests venous insufficiency.

A. Inspect for pedal edema. B. Obtain a blood pressure. C. Listen to fetal heart rate. D. Ask for a 24-hour diet recall.

Correct Answer is B

Explanation

A. Inspect for pedal edema. While pedal edema can be a sign of preeclampsia, obtaining blood pressure is a more immediate and crucial assessment.

B. Obtain a blood pressure. This is the correct next step, as rapid weight gain and nausea/vomiting can be symptoms of preeclampsia, which is often accompanied by hypertension.

C. Listen to foetal heart rate. This is important but secondary to assessing the mother's condition, especially when preeclampsia is suspected.

D. Ask for a 24-hour diet recall. This might be relevant for nutritional assessment but is not the priority when preeclampsia is suspected.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

Correct Answer is D

Explanation

A client who is 32 weeks gestation arrives at the clinic reporting nausea and vomiting for the past 24 hours. The nurse reviews the record and observes there has been a rapid weight gain over six weeks. Which action should the nurse implement next?

Correct Answer is B

Explanation

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

A woman comes to the clinic for her first prenatal visit. The nurse is conducting a health history and the woman begins to cry when asked about previous pregnancies. Which response is best for the nurse to provide?

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

When assessing a client's range of motion, the nurse notes crepitation with movement of the left knee. Which information in the client's history is most likely related to this finding?

During a routine health screening of an adult client, the nurse notes several changes that have occurred over the past year. Which change indicates the need for a bone density screening?

A pregnant, homeless woman who has received no prenatal care presents to the clinic in her third trimester because she is having vaginal bleeding, but reports that she is not in pain. Ultrasound reveals a placenta previa. Which action should the nurse implement?

Using the Ballard Gestational Age Assessment Tool, the nurse determines that a 15-minute old client has a gestational age of 42 weeks. Based on this finding, which intervention is most important for the nurse to implement?

The nurse hears crackles when auscultating a client's lung sounds. Which is an accurate description of the sound of crackles?