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.

Answer and Explanation

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.

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Correct Answer is B

Explanation

A. It reflects a desire to improve physical fitness, which is a common and generally positive goal. However, if this statement were accompanied by an excessive focus on weight loss or extreme measures to achieve fitness, it could indicate a problem, but on its own, this statement is not clearly indicative of cognitive distortion.
B. It reflects "all-or-nothing thinking," a common cognitive distortion in eating disorders. This pattern of thinking involves seeing things in black and white, where a small lapse in diet is perceived as a complete failure, leading to excessive and irrational behavior, such as consuming more than intended.
C. It shows a strong fear of gaining weight, which is typical in anorexia nervosa. However, it is more a sign of extreme concern about body image rather than a specific cognitive distortion pattern. Cognitive distortions often involve faulty logic or irrational beliefs, and this statement is more about an emotional response to weight gain.
D. Cutting food into small pieces can be a behavioral characteristic or ritual for someone with anorexia nervosa, but it does not necessarily reflect a cognitive distortion on its own. It might be a way to control portions or prolong the eating process, but it is not a direct example of distorted thinking.

A. "The medication works by decreasing gastric acid secretions." B. "The medication relieves nausea by promoting gastric emptying." C. "The medication relieves nausea by slowing peristalsis." D. "The medication works by relaxing gastric muscles."

Correct Answer is B

Explanation

A. Decreasing gastric acid secretions is not the primary mechanism of action for metoclopramide. This action is more characteristic of medications like proton pump inhibitors (PPIs) or H2 receptor antagonists, which reduce stomach acid to help with conditions such as GERD or peptic ulcers.
B. Promoting gastric emptying is the correct explanation for how metoclopramide relieves nausea. Metoclopramide acts as a prokinetic agent, meaning it enhances gastrointestinal motility by increasing the movement of the stomach and intestines.
C. Slowing peristalsis is not the mechanism of action for metoclopramide. In fact, metoclopramide does the opposite by increasing peristalsis and gastrointestinal motility. Slowing peristalsis would typically exacerbate nausea and lead to delayed gastric emptying, which metoclopramide aims to counteract.
D. Relaxing gastric muscles is not how metoclopramide works. Metoclopramide’s primary action is to increase gastrointestinal motility rather than relaxing the gastric muscles. Other medications, such as antispasmodics, might be used to relax gastrointestinal muscles, but metoclopramide is not used for this purpose.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing an adolescent client who has anorexia nervosa. Which of the following client statements is a sign of cognitive distortion?

Correct Answer is B

Explanation

A nurse is caring for a client who has nausea and a prescription for metoclopramide intermittent IV bolus every 4 hr as needed. The client asks the nurse how metoclopramide will relieve her nausea. Which of the following explanations should the nurse provide?

Correct Answer is B

Explanation

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