The nurse is performing a musculoskeletal assessment of a client in a nursing home who had a stroke 2 years ago and who has right-sided hemiplegia. The nurse notes that the girth of the client's right calf is 2 inches less in diameter than the left calf. The nurse attributes the decreased girth to:
edema in left lower extremity.
atrophy of right calf muscle.
increased use of left calf muscle.
bruising in right lower extremity.
The Correct Answer is B
Muscle mass is maintained through a constant cycle of protein synthesis and degradation, which is heavily dependent on mechanical tension and neuromuscular stimulation. Chronic immobilization or upper motor neuron lesions, such as those occurring in a stroke, lead to the loss of myofibrillar proteins. This results in a visible and measurable reduction in muscle diameter, representing a transition from functional tissue to a hypotrophic state.
A. edema in left lower extremity: Edema involves the accumulation of fluid in the interstitial space, which would cause an increase in the girth of the affected limb. If the left calf were edematous, it would appear swollen and potentially demonstrate pitting upon pressure. The question specifies a decrease in the right calf, making tissue wasting on the paralyzed side the more plausible physiological explanation.
B. atrophy of right calf muscle: Disuse atrophy occurs when a muscle is no longer subjected to the contractile demands of voluntary movement or weight-bearing. In the case of hemiplegia, the lack of neural signals to the right calf prevents the maintenance of muscle bulk. This pathophysiological regression is a common long-term complication of stroke and prolonged physical inactivity.
C. increased use of left calf muscle: While the client may rely more heavily on the non-paralyzed left side for mobility, this would lead to hypertrophy rather than a relative deficit. Muscle enlargement on the left does not explain the significant 2-inch loss of volume on the right side. The primary clinical concern in hemiplegia is the catabolic loss of tissue on the affected side.
D. bruising in right lower extremity: Bruising, or ecchymosis, involves the extravasation of blood and typically causes localized inflammatory swelling rather than a reduction in girth. A bruise would not result in a symmetrical 2-inch decrease in the circumference of the calf muscle. Atrophy is a chronic structural change, whereas bruising is an acute, superficial vascular event.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Survival skills in diabetes management focus on immediate stabilization and preventing life-threatening metabolic crises. Patients must master the ability to differentiate between blood glucose extremes to apply correct reversal protocols, such as ingesting simple carbohydrates or administering insulin. Failure to recognize these acute states can lead to permanent neurological damage or cardiovascular collapse within a very short timeframe.
A. Recognition of hypoglycemia and hyperglycemia: Identifying glycemic extremes is the most fundamental skill for preventing acute mortality in newly diagnosed patients. Hypoglycemia requires immediate glucose replacement to prevent neuroglycopenia, while hyperglycemia signals a need for insulin adjustment or hydration. This knowledge forms the baseline for safe independent living and prevents emergency department visits.
B. Management of diabetic ketoacidosis: DKA is a complex medical emergency requiring intravenous fluid resuscitation, electrolyte replacement, and titrated insulin infusions in a clinical setting. A newly diagnosed patient cannot manage this life-threatening acidosis at home and must instead focus on early prevention. Survival skills emphasize when to seek professional help rather than performing advanced inpatient protocols.
C. Signs and symptoms of diabetic nephropathy: Chronic complications like microalbuminuria and renal filtration decline take years to develop and are not part of immediate survival training. Education on long-term sequelae is usually deferred until the patient has stabilized their daily blood glucose monitoring and injection routines. Focus remains on preventing acute crises rather than discussing potential chronic organ failure.
D. Effects of surgery and pregnancy on blood sugar levels: While physiological stress and hormonal shifts significantly impact glycemic control, these are advanced topics addressed during specific life transitions. Initial education focuses on the patient’s current baseline and daily management needs. Addressing these complex scenarios prematurely can overwhelm the learner and detract from the foundational skills needed for immediate safety.
Correct Answer is B
Explanation
Scoliosis in adolescents often presents as an asymmetrical trunk alignment that becomes more pronounced during the Adams Forward Bend Test. The rotational deformity of the vertebrae causes the ribs to push backward, creating a rib hump on the convex side of the curve. Early detection during school screenings is vital to implement orthotic bracing before skeletal maturity is reached.
A. Lordosis: This condition involves an inward curvature of the lower back and does not produce lateral asymmetry or a prominent scapula. While it may affect posture, it is typically viewed from a lateral profile rather than a posterior view. It lacks the rotational component that characterizes the rib cage changes seen in this client.
B. Scoliosis: The leveling of the shoulders and the presence of a unilateral scapular prominence are classic indicators of lateral spinal deviation. Bending forward accentuates the thoracic rotation associated with this condition, making it a definitive physical assessment finding. This disorder requires serial radiographic monitoring to track the Cobb angle of the curvature.
C. Muscular dystrophy: This is a group of genetic diseases characterized by progressive muscle fiber degeneration and weakness. While it can eventually lead to secondary spinal deformities, the primary presentation involves proximal muscle wasting and a positive Gowers' sign. It is not defined by the asymmetrical skeletal findings described in the clinical scenario.
D. Kyphosis: As discussed previously, kyphosis results in a "slouching" posture due to the outward curvature of the thoracic spine. While it affects the upper back, it is a symmetrical deformity and does not cause one scapula to be more prominent than the other. It is assessed by looking at the patient's sagittal alignment rather than lateral trunk symmetry.
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