A nurse is preparing a client for ambulation. Which of the following actions should the nurse take to determine the client's level of strength?
Palpate the client's pedal pulses.
Ask the client how strong she feels today.
Ask the client to touch her finger to her nose.
Ask the client to push her feet against the nurse's palms.
The Correct Answer is D
A. Palpating the pedal pulses is important for assessing circulation and vascular status, not for evaluating muscle strength. This action helps in determining blood flow to the lower extremities but does not provide information about the client’s muscle strength or ability to ambulate.
B. Asking the client how strong she feels provides subjective information about her perceived strength but does not objectively assess muscle strength. This method relies on the client's self-assessment, which may not always be accurate or reliable.
C. Touching the finger to the nose is a test of coordination and can help assess motor function and neurological status. While it provides information about coordination, it does not specifically measure the client’s overall muscle strength, especially in the lower extremities, which is critical for safe ambulation.
D. Asking the client to push her feet against the nurse’s palms is an effective way to assess lower
extremity muscle strength. This action allows the nurse to gauge the client’s ability to exert force with
their legs, which is essential for ambulation and overall mobility.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is D
Explanation
A. This term refers to the presence of excess fat in the stool, which makes it appear greasy or oily. Steatorrhea is usually associated with malabsorption issues such as celiac disease or chronic pancreatitis. The guaiac test does not detect steatorrhea; it specifically tests for blood in the stool.
B. These are organisms that live in or on another organism (host) and can be detected in stool samples through different tests, such as stool ova and parasite exams. The guaiac test does not detect parasites; it is designed to identify hidden blood in the stool.
C. Various bacterial infections can be identified through stool cultures or other specific tests. The guaiac test is not used to detect bacteria; it is focused on identifying the presence of blood in the stool.
D. The guaiac test is used to detect occult (hidden) blood in the stool. The presence of blood can be an indication of gastrointestinal issues, such as bleeding from ulcers, polyps, or tumors. The test works by using a chemical reaction (with guaiac) that turns blue in the presence of hemoglobin (a component of blood).
Correct Answer is D
Explanation
A. Tempeh is a fermented soybean product, but it's not a reliable source of vitamin B12. While it can contain some vitamin B12, the amount can vary depending on the production process.
B. Sunflower margarine is a plant-based product and does not contain vitamin B12.
C. Sea vegetables can contain some vitamin B12, but the amount is often unreliable and can vary depending on the type of sea vegetable and where it was grown.
D. Algae is the most reliable plant-based source of vitamin B12. It's a common ingredient in many vegan vitamin B12 supplements and fortified foods.
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