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
Related Questions
Correct Answer is A
Explanation
A. Checking the stockings for wrinkles is an important action. Wrinkles or folds in the stockings can create areas of increased pressure, which might lead to discomfort or skin breakdown and reduce the effectiveness of the stockings in preventing DVT. Ensuring that the stockings are smooth and free from wrinkles helps maintain proper compression and comfort.
B. Measuring the size of the client's foot is not typically required for properly fitting antiembolic stockings. The key measurements for antiembolic stockings are usually related to the calf, thigh, and sometimes the knee, not the foot.
C. Removing the stockings once each day is not usually recommended unless specifically instructed by a healthcare provider. Antiembolic stockings are generally worn continuously throughout the day and removed only for specific reasons, such as skin assessment or hygiene.
D. Applying the stockings while the client is sitting in a chair is not the preferred method. Antiembolic stockings should be applied while the client is lying down or in a supine position. This helps ensure that the stockings are applied evenly and that they provide consistent compression without causing undue pressure or discomfort.
Correct Answer is B
Explanation
A. H2RAs are not typically associated with causing or alleviating diarrhea. Their primary function is to reduce gastric acid secretion, which is not directly related to diarrhea. Therefore, cessation of diarrhea is not an indicator of the therapeutic effect of an H2RA.
B. Heartburn is a common symptom associated with excess stomach acid, often due to conditions like GERD. H2RAs work by decreasing the amount of acid produced in the stomach, which helps relieve heartburn. Therefore, relief of heartburn is a direct indication that the H2RA is achieving its therapeutic effect.
C. Constipation is not a common effect of H2RAs; instead, it is often more related to other types of medications or dietary issues. Since H2RAs are designed to reduce stomach acid and not to affect bowel movements, the absence of constipation is not a relevant outcome for assessing the effectiveness of an H2RA.
D. Flatus, or gas, is not directly affected by H2RAs. The primary purpose of H2RAs is to manage acid- related conditions, and while gastrointestinal symptoms might be related, passage of flatus is not a specific indicator of the effectiveness of an H2RA.
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