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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Crutches should not be used to support body weight under the arms, as this can cause nerve damage or discomfort. Instead, weight should be supported on the hands and arms, with the crutches positioned to support the client’s weight. Proper use involves placing the crutches slightly in front of the feet, with weight supported on the hands, not the underarms.
B. While it's important to be aware of your surroundings, looking down at your feet can be counterproductive as it may affect balance and coordination. The client should maintain an upright posture and look ahead to ensure proper gait and balance while moving. This helps in coordinating the movement of crutches and feet more effectively.
C. In a four-point gait, each crutch and foot move alternately, which is different from the three-point gait. The three-point gait involves moving both crutches and the affected leg forward simultaneously, followed by the unaffected leg.
D. In the three-point gait, the client moves both crutches forward at the same time while keeping the affected leg off the ground or in a non-weight-bearing position. Then, the client swings the unaffected leg forward to step past the crutches. This method ensures that weight is only placed on the unaffected leg while moving.

A. "I should drink about 2 liters of fluid each day." B. "I should not drink alcoholic beverages during my pregnancy." C. "I can have a moderate amount of caffeine daily." D. "I should increase my calcium intake to 1,500 milligrams per day"

Correct Answer is D

Explanation

A. Drinking adequate fluids is essential during pregnancy to support overall health and amniotic fluid levels. A general recommendation is to drink about 2 to 3 liters (8-12 cups) of fluids per day. This includes water, and sometimes other beverages and soups.
B. It is well-established that alcohol consumption during pregnancy is harmful and can lead to serious conditions such as fetal alcohol syndrome. The advice to avoid alcohol entirely during pregnancy is accurate and reflects current medical guidelines.
C. Moderate caffeine consumption is generally considered acceptable during pregnancy. Most guidelines suggest limiting caffeine intake to about 200-300 milligrams per day (equivalent to about 1-2 cups of coffee). This advice is consistent with current recommendations.
D. The recommended daily calcium intake during pregnancy is typically around 1,000 milligrams per day for most pregnant women. An intake of 1,500 milligrams per day is higher than the usual recommendation and may not be necessary unless specifically advised by a healthcare provider for individual circumstances.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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 teaching a client about crutch walking using the three-point gait. Which of the following statements by the nurse should be included in the teaching?

Correct Answer is D

Explanation

A nurse is providing education to a client during the first prenatal visit. Which of the following statements by the client should indicate to the nurse a need for clarification?

Correct Answer is D

Explanation

A nurse is caring for a client who has impaired mobility. Which of the following support devices should the nurse plan to use to prevent the client from developing plantar flexion contractures?

A nurse is providing discharge teaching for a client who has acute pancreatitis and has a prescription for fat-soluble vitamin supplements. The nurse should instruct the client to take a supplement for which of the following?

A nurse is discussing comorbidities associated with eating disorders with a newly admitted client. Which of the following conditions should the nurse include in the discussion? (Select all that apply.)

A nurse is reviewing the medication list for a client who has a new diagnosis of a small bowel obstruction. The nurse should withhold which of the following medications?

A nurse is assisting a client who is postpartum with her first breastfeeding experience. When the client asks how much of the nipple she should put into the newborn's mouth, which of the following responses should the nurse make?

A nurse is caring for a client who requires cold applications with an ice bag to reduce the swelling and pain of an ankle injury. Which of the following actions should the nurse take?

A nurse is assessing an adolescent female client who has anorexia nervosa. Which of the following findings should the nurse expect?

A nurse is caring for a client who receives intermittent enteral feedings through an NG tube. Before administering a feeding, the nurse should measure the gastric residual for which of the following purposes?