The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

Abduct each hip while the client is supine.

Flex the hip and knee while standing.

Observe balance while the client stands.

Inspect gluteal folds for symmetry.

Answer and Explanation

The Correct Answer is B

A) Abduct each hip while the client is supine:
While assessing hip abduction can provide information about hip joint mobility, it may not be the most appropriate initial assessment for hip dysfunction. This action primarily evaluates the range of motion but may not specifically target dysfunction in the hip region.

B) Flex the hip and knee while standing:
Flexing the hip and knee while the client is standing can help assess hip function, particularly in weight-bearing positions. This action can reveal limitations in hip mobility and detect dysfunction such as pain or weakness during movement.

C) Observe balance while the client stands:
Observing balance while the client stands is important for assessing overall lower extremity function, including the hips. However, it may not specifically target dysfunction in the hip region and may provide more general information about mobility and stability.

D) Inspect gluteal folds for symmetry:
Inspecting gluteal folds for symmetry can help identify asymmetry or abnormalities in the hip region, but it may not provide direct information about hip dysfunction. This action is more focused on assessing external appearance rather than functional movement or mobility.

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Correct Answer is C

Explanation

Answer: C. Document the presence of borborygmi.

Rationale:

A. Elevate the head of the client's bed immediately:
While elevating the head of the bed may be appropriate in certain situations, it is not the necessary immediate action in this context. The presence of loud, high-pitched bowel sounds does not indicate a need for repositioning the client. Instead, the nurse should first focus on assessing the findings before making any positional changes.

B. Use the bell of the stethoscope to auscultate again:
The bell of the stethoscope is typically used for lower frequency sounds, such as heart murmurs or certain vascular sounds. Since the nurse has already identified high-pitched bowel sounds using the diaphragm, switching to the bell is not appropriate for this situation. The diaphragm is better suited for detecting the types of sounds the nurse is hearing.

C. Document the presence of borborygmi:
Borborygmi refers to the loud, gurgling bowel sounds that can indicate increased intestinal activity. Documenting this finding is essential as it provides a clear record of the client's bowel sounds at this moment. This documentation can aid in monitoring the client's gastrointestinal function and is crucial for continuity of care.

D. Auscultate the remaining two quadrants:
While it is important to auscultate all quadrants to get a complete assessment of bowel sounds, the immediate action after hearing significant sounds in two quadrants is to document the findings. Continuing the assessment can follow, but the documentation serves as an important step in patient care and communication among the healthcare team.

A. Obese, serious threat to well-being. B. Appropriate weight for height, good general health. C. Extreme obesity, at risk for multiple co-morbidities. D. Undernutrition, at risk for malnutrition.

Correct Answer is A

Explanation

A) Obese, serious threat to well-being: A BMI of 32 kg/m² places the client in the category of obesity (BMI ≥ 30 kg/m²). Obesity is a significant health concern associated with increased risks for various conditions such as cardiovascular disease, diabetes, hypertension, and certain cancers. The client's BMI indicates that she is obese, which poses a serious threat to her overall well-being and health.

B) Appropriate weight for height, good general health: This is incorrect because a BMI of 32 kg/m² does not fall within the normal range of 18.5 to 24.9 kg/m². The client is not at an appropriate weight for her height and is not considered to be in good general health based on this BMI.

C) Extreme obesity, at risk for multiple co-morbidities: While a BMI of 32 kg/m² does indicate obesity, it does not reach the threshold for extreme obesity (BMI ≥ 40 kg/m²). Therefore, the client is not categorized as extremely obese, although she is still at risk for several co-morbidities associated with obesity.

D) Undernutrition, at risk for malnutrition: This is incorrect because a BMI of 32 kg/m² is indicative of excess weight, not undernutrition or malnutrition. The client's BMI suggests an over-nutrition status rather than undernutrition.

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The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

After placing a client in a supine position, the nurse uses the diaphragm of the stethoscope to auscultate bowel sounds and hears a loud, high pitched almost continuous gurgling in two quadrants. Which action should the nurse implement?

Correct Answer is C

Explanation

Rationale:

The nurse is assessing a young adult female who is 5 feet 5 inches (165 cm) and has a body mass index (BMI) score of 32 kg/m2. Based on this BMI, what should the nurse deduce about this client's general health? Reference Range: Body Mass Index (BMI) [Normal 18.5 to 24.9 kg/m2]

Correct Answer is A

Explanation

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