The nurse is preparing to examine a client's mouth floor. To move the tongue to one side for this examination, which tool should the nurse use?

Choice A Reason:
Family History is used to document health events in the patient's family, including diseases that may be hereditary or place the patient at risk. The statement about feeling like an elephant is sitting on the chest is not related to family health but is a description of the patient's current symptoms.

Choice B Reason:
Past Medical History includes information about the patient's past health issues, surgeries, hospitalizations, allergies, and treatments. It does not include current symptoms or the reasons for the current hospital visit.

Choice C Reason:
The Chief Complaint is the section where the nurse documents the primary reason for the patient's visit in their own words. The phrase "feels like an elephant is sitting on his chest" is a classic description of chest pain or discomfort, often associated with cardiac issues, and would be documented here as it represents the patient's main concern.

Choice D Reason:
Present Illness or History of Present Illness would include a detailed account of the development of the patient's illness or health concern. While it is closely related to the Chief Complaint, it is more detailed and includes the onset, duration, and character of the symptoms, among other aspects. The initial statement would be part of the Chief Complaint, which leads into the more detailed History of Present Illness.

Choice a reason:
Draping body areas that are not being assessed is important for maintaining the client's privacy and comfort, but it is not the highest priority when dealing with a client with generalized muscle weakness. The primary concern is to prevent further strain or injury during the examination.

Choice b reason:
Limiting position changes as much as possible is the priority when examining a client with generalized muscle weakness. Frequent or unnecessary movements can cause fatigue, discomfort, and may even be unsafe if the client has severely compromised muscle strength. The nurse should plan the examination to minimize the number of times the client needs to change positions.

Choice c reason:
Hand-washing throughout the exam is a standard practice to prevent the spread of infection. While it is crucial for both the client's and the nurse's safety, in the context of a client with generalized muscle weakness, the priority is to conduct the exam in a way that does not exacerbate the client's condition.

Choice d reason:
Using alcohol swabs to clean the stethoscope before and after the exam is also a standard infection control practice. However, it is not the most immediate concern when prioritizing the steps of a physical examination for a client with muscle weakness.