In completing a physical assessment of a young adult, the clinic nurse observes muscular atrophy of the right thigh and calf. To gather additional data related to this finding, which action should the nurse take?

Obtain vital signs and oxygen saturation.

Calculate the body mass index (BMI).

Measure degree of skin elasticity.

Compare muscle strength bilaterally.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Obtain vital signs and oxygen saturation: While vital signs and oxygen saturation provide essential information about cardiovascular and respiratory status, they do not directly assess or explain localized muscle atrophy, which points more toward a musculoskeletal or neurologic issue.

B. Calculate the body mass index (BMI): BMI evaluates overall body weight relative to height and can identify underweight, overweight, or obesity. However, it does not provide specific information about asymmetrical muscle wasting or localized muscle function.

C. Measure degree of skin elasticity: Skin elasticity assessment is useful for hydration status but is unrelated to muscular strength or the presence of atrophy. It would not offer meaningful information about the function or cause of the observed muscle changes.

D. Compare muscle strength bilaterally: Comparing muscle strength on both sides allows the nurse to assess for weakness, nerve impairment, or disuse atrophy. This focused and direct examination is essential to determine the extent and functional impact of the observed muscle wasting.

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Correct Answer is D

Explanation

Rationale:
A. Hematocrit: Hematocrit measures the proportion of red blood cells in the blood and helps assess for anemia or dehydration, but it does not directly reflect short-term changes in nutritional status or protein stores.

B. Serum calcium: Serum calcium levels assess electrolyte balance and bone health but are not specific indicators of overall nutritional status. Calcium levels can be maintained even when nutritional intake is poor.

C. Hemoglobin: Hemoglobin evaluates oxygen-carrying capacity and can suggest anemia, which may indirectly reflect poor nutrition, but it is not as sensitive a marker for acute or current nutritional status as prealbumin.

D. Serum prealbumin: Serum prealbumin is a sensitive marker of recent nutritional intake and protein status, reflecting short-term changes in nutrition. It is the most important laboratory value to assess when evaluating a client for malnutrition, especially in the setting of appetite loss and generalized malaise.

A. "Can you recall the date the Twin Towers in New York were destroyed?" B. "What is the difference between a hamster and a rabbit as a pet?" C. "Should someone who lives in a glass house throw stones?" D. "Do you write checks if you know the bank account is overdrawn?"

Correct Answer is D

Explanation

Rationale:
A. "Can you recall the date the Twin Towers in New York were destroyed?": This question assesses memory, specifically long-term memory, rather than judgment. Remembering historical events evaluates cognitive recall ability but does not explore the client’s decision-making process.

B. "What is the difference between a hamster and a rabbit as a pet?": This question primarily assesses abstract thinking and categorization rather than judgment. It helps evaluate how the client organizes concepts but does not directly provide insight into practical decision-making or problem-solving skills.

C. "Should someone who lives in a glass house throw stones?": This proverb assesses abstract thinking and the ability to interpret symbolic meanings, rather than directly evaluating judgment. Interpretation of proverbs reflects cognitive function but not necessarily real-life decision-making capacity.

D. "Do you write checks if you know the bank account is overdrawn?": This question assesses practical judgment by exploring the client's ability to make appropriate decisions regarding real-world financial behavior. It directly addresses reasoning, consequences of actions, and impulse control, which are key elements of judgment evaluation.

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In completing a physical assessment of a young adult, the clinic nurse observes muscular atrophy of the right thigh and calf. To gather additional data related to this finding, which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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