A client is seen in the emergent care clinic for right wrist pain with a pattern of ecchymosis observed on the wrist. Which motion should the nurse instruct the client to perform to assess the wrist mobility?
Hyperextension and palmar flexion.
Plantar flexion.
Forearm pronation.
Forearm supination.
The Correct Answer is A
Choice A Reason:
Hyperextension and palmar flexion are correct. Hyperextension involves moving the wrist joint backward, testing its ability to extend beyond its neutral position. Palmar flexion involves moving the wrist joint forward, testing its ability to flex toward the palm. These movements collectively assess the range of motion of the wrist joint in both directions, which is essential for identifying any limitations or pain associated with certain movements. Since the client presents with right wrist pain and ecchymosis, assessing both hyperextension and palmar flexion can help determine if there's any injury or impairment affecting the wrist's mobility.
Choice B Reason:
Plantar flexion is incorrect. Plantar flexion refers to a movement of the foot and ankle, not the wrist. Therefore, instructing the client to perform plantar flexion would not assess the wrist's mobility and is not relevant to the presented scenario of right wrist pain with ecchymosis.
Choice C Reason:
Forearm pronation is incorrect. Forearm pronation involves rotating the forearm so that the palm faces downward. This movement primarily assesses the pronation and supination of the forearm, not the wrist's mobility. Since the client's symptoms are specific to the wrist, assessing forearm pronation would not directly evaluate the wrist's range of motion.
Choice D Reason:
Forearm supination is incorrect. Forearm supination involves rotating the forearm so that the palm faces upward. Similar to forearm pronation, this movement primarily assesses the forearm's mobility, not the wrist's mobility. Therefore, instructing the client to perform forearm supination would not be an appropriate method for assessing the wrist's range of motion in the context of right wrist pain with ecchymosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A Reason:
Fluid volume excess is incorrect. Fluid volume excess refers to an overabundance of fluid in the body, leading to symptoms such as edema, weight gain, and hypertension. However, a BMI of 14 kg/m^2 indicates underweight, not fluid volume excess. Therefore, this choice is incorrect.
Choice B Reason:
Unbalanced nutrition, less than body needs is correct. A BMI of less than 18.5 indicates underweight according to the provided reference range. Underweight individuals often do not consume enough nutrients to meet their body's needs, leading to potential nutritional deficiencies. Therefore, the nursing problem of "Unbalanced nutrition, less than body needs" is appropriate for addressing the client's low BMI.
Choice C Reason:
Unbalanced nutrition, greater than body needs is incorrect. This choice would be more applicable if the client's BMI indicated overweight or obesity, as it suggests an excess intake of nutrients relative to the body's needs. However, a BMI of 14 kg/m^2 indicates underweight, not excess weight. Therefore, this choice is incorrect.
Choice D Reason:
Fluid volume deficit is incorrect. Fluid volume deficit refers to a decreased amount of fluid in the body, leading to symptoms such as dehydration, decreased urine output, and hypotension. However, a low BMI does not necessarily indicate fluid volume deficit; it primarily reflects undernutrition. Therefore, this choice is incorrect.
Correct Answer is C
Explanation
Choice A Reason:
Ask about recent abdominal trauma: in this case, the depressed umbilicus is a normal finding, so no further action related to trauma assessment is necessary.
Choice B Reason:
Palpate the area for masses: Palpating the area for masses is a good practice during abdominal assessments. However, in the context of a depressed umbilicus, this finding is not indicative of an abnormal mass. Therefore, palpation is not specifically warranted.
Choice C Reason:
Document the normal finding: Correct! A depressed umbilicus that lies below the surface of the abdomen is considered a normal variation. Documenting this finding ensures accurate and comprehensive assessment documentation.
Choice D Reason:
Observe the midline for scarring: While observing the midline for scarring is relevant in some situations (such as assessing for surgical scars), it’s not directly related to the depressed umbilicus. Therefore, this action is not necessary based on the specific finding described.
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