While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

Compare measured circumferences of each extremity joint.

Instruct the client to walk across the room and observe the gait.

Perform passive range of motion and compare the findings.

Measure the length of each leg and document the findings.

Answer and Explanation

The Correct Answer is D

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Correct Answer is D

Explanation

A. Notify the healthcare provider. While notifying the healthcare provider is important if the issue persists, the nurse should first attempt to confirm the absence of pulses using other methods to ensure it is not a technical error or due to poor technique.

B. Apply warm blankets to both feet. Warming the feet might help if the pulses are weak due to vasoconstriction from cold, but this is not the most immediate or effective action to determine the presence of pulses.

C. Palpate pulse points with legs dependent. Having the legs in a dependent position might increase blood flow to the lower extremities, potentially making pulses easier to palpate. However, this is not as reliable as using more advanced technology.

D. Use a doppler ultrasonic stethoscope. Using a Doppler device is the best next step if pulses are not palpable. Dopplers can detect blood flow that is not palpable, providing more accurate assessment of circulation in the extremities before notifying the healthcare provider.

A. Document the client's asymmetrical thoracic movement during inspiration. B. Assist the client to a position that helps the client breathe more easily. C. Provide the client an incentive spirometer to increase respiratory effort. D. Encourage the client to continue to breathe deeply to expand the lungs.

Correct Answer is B

Explanation

A. Documenting asymmetrical thoracic movement: While this might be a finding, it's not the most urgent action.

B. Assist the client to a position that helps the client breathe more easily. Sternocleidomastoid, trapezius, and abdominal muscle use: These muscles are accessory muscles that help with breathing when the diaphragm and intercostal muscles (primary muscles of respiration) are not functioning optimally. This use suggests laboured breathing. Priority action: The client's respiratory distress is the most pressing concern.

C. Incentive spirometer: This device helps improve lung expansion but is not the first-line intervention in this situation where the client is already struggling to breathe.

D. Encouraging deep breaths: This might further strain the respiratory muscles.

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While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

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Naxlex Comprehensive Predictor Exams

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

Correct Answer is D

Explanation

While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?

Correct Answer is B

Explanation

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