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.
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Would you like to talk about what is bothering you?" This empathetic approach acknowledges the client's emotional state and opens the door for them to express their concerns, which might be related to the diagnosis, fear of injections, or other anxieties.
B. "Do you feel like practicing insulin injections now?" This disregards the client's emotional state and might be perceived as insensitive.
C. "I know you are afraid, but I am here to help you." While offering reassurance, it assumes the client's fear without allowing them to express their emotions.
D. "Before you can go home you must learn how to give insulin." This is a directive and doesn't address the client's emotional response. It's important to prioritize addressing their concerns before proceeding with teaching.
Correct Answer is ["9"]
Explanation
To determine the Apgar score for the newborn infant, we assess five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each parameter is scored from 0 to 2, with 2 being the highest score. Let's evaluate each parameter:
- Heart rate: 150 beats/minute --> Score of 2.
- Respiratory effort: Vigorous cry present --> Score of 2.
- Muscle tone: Good muscle tone with total flexion --> Score of 2.
- Reflex irritability: Quick reflex irritability noted --> Score of 2.
- Color: Dusky and cyanotic skin color --> Score of 1.
Now, we sum up the scores: 2+2+2+2+1=92+2+2+2+1=9
Therefore, the Apgar score for this infant is 9.
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