When assessing an ambulatory patient, the nurse observes that both arms swing freely in alternation with leg swings. Which of the following is being assessed?

Muscle strength

Gait

Alignment

Joint function

Answer and Explanation

The Correct Answer is B

A) Muscle strength: While muscle strength can influence gait, it specifically refers to the ability of muscles to exert force against resistance. Assessing muscle strength involves different techniques, such as manual muscle testing, rather than observing arm and leg movements.
B) Gait: The observation that both arms swing freely in alternation with leg swings is a direct assessment of the patient's gait. A normal gait pattern includes coordinated movements of the arms and legs, indicating proper motor function and balance.
C) Alignment: This term refers to the positioning of the body and its parts in relation to one another. While alignment can impact gait, it is not specifically assessed by observing the movement of the arms and legs.
D) Joint function: Joint function assessment typically focuses on the range of motion, stability, and mobility of individual joints. Observing the swing of arms and legs provides insight into overall gait rather than specific joint function.

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Correct Answer is C

Explanation

A) "The client may be having a cardiac event": While this statement indicates a potential concern, it lacks specific details about the client's current condition. It suggests a possibility but does not clearly communicate the immediate issue or symptoms being experienced.

B) "The client needs an EKG. Please see her immediately": This statement expresses urgency and a request for action but does not provide the necessary context or information about the client's symptoms. It is more aligned with the "Request" part of SBAR rather than the "Situation."

C) "The client is experiencing chest pain and shortness of breath": This statement accurately describes the current situation the client is facing. It provides essential information regarding the symptoms the nurse is observing, making it a clear example of the "Situation" in the SBAR framework. This information is critical for the provider to understand the urgency of the situation.

D) "The client's admitting diagnosis is stage 2 breast cancer": While this statement provides important background information, it does not reflect the immediate situation that requires attention. It does not address the current health issue that is prompting the nurse to contact the provider.

A. Dietary history from the patient B. BMI (Body Mass Index) C. Patient history of alcohol intake D. Patient complaint of weight loss

Correct Answer is B

Explanation

A) Dietary history from the patient: This information is subjective as it relies on the patient’s personal account of their eating habits, which may be influenced by memory or perception. It does not provide measurable data.

B) BMI (Body Mass Index): This is an objective measure calculated from a person’s height and weight. It provides quantifiable data that can be used to assess nutritional status and potential health risks associated with body weight.

C) Patient history of alcohol intake: This information is subjective as it is based on the patient’s self-report. It does not provide direct evidence and may vary depending on how the patient perceives their alcohol consumption.

D) Patient complaint of weight loss: This is also subjective data, as it relies on the patient’s perception of their weight change. It does not provide concrete measurements and can be influenced by various factors such as mood or misunderstanding of the situation.

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When assessing an ambulatory patient, the nurse observes that both arms swing freely in alternation with leg swings. Which of the following is being assessed?

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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