To assess for muscle atrophy in the legs, which action should the nurse take?

Gently press over each shin and measure indentation.

Use a goniometer to measure and compare the legs.

Compare the appearance of the legs bilaterally.

Observe the client during heel-toe ambulation.

Answer and Explanation

The Correct Answer is C

A.   Pressing over the shins to measure indentation is a technique used to assess for edema, not muscle atrophy. Edema refers to fluid accumulation in the tissues, which can cause an indentation when pressed, whereas muscle atrophy involves a reduction in muscle mass and would not be detected by this method.
B.   A goniometer is a tool used to measure the range of motion of joints, not muscle size. While it can be useful in assessing joint mobility and flexibility, it does not provide information about muscle mass or atrophy.
C.   Comparing the appearance of the legs bilaterally is an appropriate method to assess for muscle atrophy. By visually inspecting and palpating both legs, the nurse can identify differences in muscle bulk and size. Muscle atrophy often presents as noticeable asymmetry between the two legs, with one leg appearing smaller or thinner compared to the other.
D.   Observing the client during heel-toe ambulation can help assess gait and functional mobility, but it is not the most direct method for evaluating muscle atrophy. While gait abnormalities can suggest underlying muscle weakness or atrophy, direct visual and palpation comparison of muscle mass provides a clearer assessment of muscle atrophy.

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Correct Answer is D

Explanation

A. Cloudy discharge is more commonly associated with infections or discharge from the genital area rather than residual urinary symptoms. While urinary tract infections (UTIs) can cause cloudy urine, this is not typically associated with suprapubic tenderness or the sensation of residual pressure alone.
B. An overactive bladder is characterized by symptoms such as frequent urination, urgency, and sometimes incontinence. However, it does not typically cause suprapubic tenderness or a sensation of residual pressure after urination. The described symptoms are more consistent with bladder outlet obstruction or incomplete bladder emptying rather than an overactive bladder.

C. Black tarry stools indicate upper gastrointestinal bleeding and are unrelated to urinary symptoms. This finding would suggest a different issue entirely, such as gastrointestinal bleeding, rather than a problem with the urinary tract or bladder. This is not consistent with the client's reported symptoms of suprapubic tenderness and sensation of residual pressure after urination.
D. A weak urinary stream is a common symptom associated with bladder outlet obstruction or conditions affecting urinary flow, such as benign prostatic hyperplasia (BPH) in older men. This finding aligns with the client's reported symptoms of suprapubic tenderness and feeling of residual pressure after urination.

A. Instruct the client to close both eyes. B. Cover the client with a warmed blanket. C. Darken the client's room environment. D. Measure the client's body temperature.

Correct Answer is A

Explanation

A. Instructing the client to close their eyes is crucial during sensory assessments, including temperature testing. This helps ensure that the client does not rely on visual cues to determine the temperature of
the stimuli, allowing the nurse to accurately assess the client’s sensory perception based purely on
touch and temperature differences.
B. Covering the client with a warmed blanket is not necessary for assessing temperature perception. This action could alter the client’s baseline sensory perception by affecting their skin temperature, which could lead to inaccurate results. The sensory assessment requires the client to experience temperature changes directly on their skin without external influences like additional warmth.
C. Darkening the room is not relevant for assessing temperature sensation. Visual impairment (like darkening the room) is not related to sensory nerve function related to temperature perception, and this step does not contribute to an accurate assessment of the client's ability to perceive temperature changes.
D. Measuring the client’s body temperature is not a direct method for assessing their sensory nerve function or temperature perception. While knowing the body temperature might be relevant for other reasons, it does not directly assess how well the client can sense temperature changes on their skin.

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To assess for muscle atrophy in the legs, which action should the nurse take?

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Naxlex Comprehensive Predictor Exams

The nurse is examining the abdomen of an older male client who expresses suprapubic tenderness on palpation. The client reports that it sometimes feels like there is still pressure in that area after urination. Which additional finding should the nurse expect with continued interview of the client?

Correct Answer is D

Explanation

In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment?

Correct Answer is A

Explanation

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