When conducting a physical examination of a client with generalized muscle weakness, which of the following is the PRIORITY for the nurse?

Draping body areas that are not being assessed.

Limit position changes as much as possible.

Hand-washing throughout the exam.

Using alcohol swabs to clean the stethoscope.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is C

Explanation

Choice A reason:
Peripheral vision is the ability to see objects and movement outside of the direct line of vision. This type of vision is assessed using different methods, such as confrontation visual field testing, where the examiner moves objects into the patient's side vision from different angles. Standing 20 feet away from a chart would not be the appropriate method to assess peripheral vision.
Choice B reason:
The assessment of external eye structures involves examining the physical appearance and condition of the eyelids, sclera, conjunctiva, and surrounding areas. This is typically done at a close range and does not require the patient to stand at a distance from a chart. The nurse would inspect these structures directly, often with the aid of a penlight for better visibility.

Choice C reason:
Distant vision is the ability to see objects far away, and it is what the nurse is preparing to assess when the client is asked to stand 20 feet from a chart. This distance is standard for the Snellen eye chart, which is used to measure visual acuity. The chart has rows of letters that decrease in size, and the patient is asked to read the smallest line of letters they can see clearly. The Snellen chart is the most common method used by eye doctors to measure visual acuity.
Choice D reason:
Near vision is the ability to see objects that are close to the eyes clearly. It is assessed using different charts, such as the Jaeger eye chart, which contains blocks of text in various type sizes. The patient is asked to read the text at a close range, typically around 14 inches, not 20 feet. Therefore, standing 20 feet away from a chart would not be the method to assess near vision.

A. A firm toothbrush is most effective in plaque removal. B. Brushing more than twice per day irritates the gums. C. Ensure that dental restorations fit well. D. Avoid flossing if there is bleeding at the gumline.

Correct Answer is C

Explanation

Choice a reason:
A firm toothbrush is not recommended for plaque removal as it can damage the gums and tooth enamel. Soft-bristled toothbrushes are preferred because they are effective at removing plaque while being gentle on the gums and enamel.

Choice b reason:
Brushing more than twice per day does not necessarily irritate the gums unless done with improper technique or with a hard-bristled toothbrush. It is important to brush gently with a soft-bristled toothbrush and to use fluoride toothpaste to maintain oral hygiene and prevent gingivitis.

Choice c reason:
Ensuring that dental restorations such as fillings and crowns fit well is crucial in preventing gingivitis. Poorly fitted restorations can trap food particles and bacteria, leading to plaque buildup and gum inflammation. Regular dental check-ups can help ensure that restorations remain intact and do not contribute to gingivitis.

Choice d reason:
Flossing should not be avoided even if there is bleeding at the gumline. Bleeding can be a sign of gingivitis, and flossing can help remove the plaque and bacteria causing the inflammation. If bleeding persists, it is important to consult a dentist.

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When conducting a physical examination of a client with generalized muscle weakness, which of the following is the PRIORITY for the nurse?

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