The nurse is assessing a client's skeletal muscle movements and strength. Which action should the nurse instruct the client to perform to evaluate prime-mover muscle groups?

Flex and hold as opposing force is applied.

Perform sets of passive range of motion.

Hold arms straight forward with eyes closed.

Stand on each foot without assistance.

Answer and Explanation

The Correct Answer is A

Rationale:
A. Flex and hold as opposing force is applied: This technique evaluates the strength of prime-mover muscle groups by having the client actively flex against resistance. It allows the nurse to assess muscle function, endurance, and the ability to maintain strength against an external force.

B. Perform sets of passive range of motion: Passive range of motion exercises assess joint flexibility and mobility but do not evaluate the client's active muscle strength since the movements are performed by the examiner rather than the client.

C. Hold arms straight forward with eyes closed: This action is part of a neurological assessment, specifically testing for proprioception and balance (Romberg test), not a direct evaluation of muscle group strength.

D. Stand on each foot without assistance: Standing on one foot assesses balance and coordination more than muscle strength. It involves neuromuscular control but does not directly isolate or test specific prime-mover muscle groups under resistance.

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Correct Answer is C

Explanation

Rationale:
A. An overactive bladder: Overactive bladder typically presents with urgency, frequency, and sometimes incontinence, but it does not usually cause suprapubic tenderness or the sensation of incomplete bladder emptying. These symptoms are more consistent with urinary retention or bladder outlet obstruction.

B. A cloudy discharge: Cloudy urinary discharge is more indicative of a urinary tract infection (UTI) rather than urinary retention. While infections can cause some bladder discomfort, the client’s description points more specifically to mechanical urinary issues rather than infection.

C. A weak urinary stream: A weak urinary stream is commonly associated with bladder outlet obstruction, often due to benign prostatic hyperplasia (BPH) in older males. The combination of suprapubic tenderness and the feeling of incomplete emptying aligns with urinary retention caused by obstruction, making this the expected additional finding.

D. Black tarry stools: Black tarry stools are usually a sign of gastrointestinal bleeding, particularly from the upper GI tract. They are unrelated to urinary symptoms and would not explain suprapubic tenderness or voiding difficulties described by the client.

A. "Have you ever considered being evaluated for a hearing aid?" B. "Do you have a history of ear infections?" C. "Is this hearing loss accompanied by any loss of balance?" D. "How is this hearing loss interfering with your daily activities of living?"

Correct Answer is D

Explanation

Rationale:
A. "Have you ever considered being evaluated for a hearing aid?": Suggesting a hearing aid too early may feel dismissive and presumes a diagnosis without a full assessment. First, the nurse needs to understand the impact and specifics of the hearing loss before recommending interventions like hearing aids.

B. "Do you have a history of ear infections?": A history of ear infections is relevant because recurrent infections can lead to conductive hearing loss. However, the pattern described—garbled words and missed sentence endings—suggests possible sensorineural hearing loss (presbycusis), making a broader functional assessment more appropriate first.

C. "Is this hearing loss accompanied by any loss of balance?": Hearing loss combined with balance issues could suggest vestibular involvement. However, in the absence of the client mentioning dizziness or falls, the more pressing need is to assess how hearing difficulties are impacting daily functioning and quality of life.

D. "How is this hearing loss interfering with your daily activities of living?": Understanding how the hearing loss affects activities of daily living helps the nurse assess the severity and functional impact. This client-centered approach guides both the urgency of intervention and the planning of supportive resources to enhance the client’s quality of life.

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The nurse is assessing a client's skeletal muscle movements and strength. Which action should the nurse instruct the client to perform to evaluate prime-mover muscle groups?

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Naxlex Comprehensive Predictor Exams

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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