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:
The Review of Systems (ROS) is a systematic approach for collecting the patient's self-reported data on all body systems. It is not typically where the narrative of symptoms is documented. Instead, the ROS is used to uncover symptoms the patient may not have mentioned during the initial recounting of their history.

Choice B Reason:
The Chief Complaint (CC) is a concise statement describing the symptom, problem, condition, diagnosis, or other factors that are the reason for the encounter, usually stated in the patient's words¹. While it does include the symptom prompting the visit, it is not the section where a detailed narrative or description of symptoms is provided.

Choice C Reason:
The History of Present Illness (HPI) is indeed where the detailed narrative of the patient's symptoms is documented. It includes the onset of the problem, the setting in which it developed, its manifestations, and any treatments to date. The HPI tells the story of the patient's chief complaint and provides context for the clinical reasoning process.

Choice D Reason:
The Past Medical History (PMH) includes information about the patient's past experiences with illnesses, operations, injuries, and treatments. It does not contain the current symptoms' narrative but rather the patient's health status before the present illness or concern.

A. Rhonchi B. Crackles C. Bronchovesicular D. Tracheal

Correct Answer is C

Explanation

Choice a reason:
Rhonchi are coarse, rattling respiratory sounds somewhat like snoring, usually caused by obstruction or secretion in the larger airways. They are not considered normal breath sounds and are typically heard in conditions such as chronic bronchitis.

Choice b reason:
Crackles are the sounds you will hear in a lung field that has fluid in the small airways. These sounds are commonly heard in patients with pneumonia, heart failure, and restrictive pulmonary diseases. They are not normal breath sounds.

Choice c reason:
Bronchovesicular sounds are normal breath sounds heard over the main bronchus area and over the upper right posterior lung field. They have a medium pitch and intensity and are heard on both inspiration and expiration. In a healthy individual, these sounds are expected to be heard in the 1st and 2nd intercostal spaces near the sternal body.

Choice d reason:
Tracheal breath sounds are harsh, high-pitched sounds heard when auscultating over the trachea in the neck. They are not normally heard over the intercostal spaces of the chest wall.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During a health history assessment, where is the symptoms description/narrative typically documented?

Correct Answer is C

Explanation

While auscultating a client's 1st and 2nd intercostal spaces, close to the sternal body, the nurse would document these normal breath sounds as which of the following?

Correct Answer is C

Explanation

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