In assessing an older adult client, the nurse notes that the client's right arm muscles feel soft and boggy. To gather additional data related to this finding, which assessment should the nurse complete next?

Determine degree of skin elasticity.

Measure muscle size and strength.

Inspect appearance of the spine.

Note 24-hour fluid intake and output.

Answer and Explanation

The Correct Answer is B

A. Determine degree of skin elasticity: While decreased skin elasticity can be a sign of aging, it doesn't directly assess muscle tone or strength.

B. Measure muscle strength: This is the most appropriate next step to confirm the nurse's initial suspicion of weak muscles. Techniques like manual muscle testing can assess muscle strength.

C. Inspect appearance of the spine: Spinal issues can affect movement and coordination, but they wouldn't necessarily explain soft and boggy muscles in one arm.

D. Note 24-hour fluid intake and output: This might be relevant for overall health assessment but doesn't directly assess muscle tone or strength.

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Correct Answer is B

Explanation

A. Bulges. Bulges might indicate abnormalities such as masses or hernias and are not considered normal findings.

B. Nontender. This is the expected finding in a healthy individual without thoracic abnormalities.

C. Tenderness. Tenderness might indicate inflammation, injury, or other underlying conditions and should be further assessed.

D. Thrill. Thrill refers to a vibrating sensation caused by turbulent blood flow and is not typically assessed during thoracic palpation.

A. Obtain a dietary consultation for nutrition teaching. B. Instruct the client in the need to use iodized salt. C. Request diagnostic laboratory testing for the client. D. Schedule a follow-up appointment in one month.

Correct Answer is C

Explanation

A. Obtain a dietary consultation for nutrition teaching: Diet might play a role in some thyroid conditions, but a referral for dietary consultation wouldn't be the first step.

B. Instruct the client in the need to use iodized salt: Iodine deficiency can cause goiter (enlarged thyroid gland), but most table salt in developed countries is iodized.

C. Request diagnostic laboratory testing for the client: This is the most appropriate next step. Blood tests can help determine the cause of the enlarged thyroid gland.

D. Schedule a follow-up appointment in one month: A follow-up might be needed, but further workup is essential to determine the cause of the finding.

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In assessing an older adult client, the nurse notes that the client's right arm muscles feel soft and boggy. To gather additional data related to this finding, which assessment should the nurse complete next?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse completes palpation of the thoracic region on an adolescent client. Which finding is considered normal for this adolescent client?

Correct Answer is B

Explanation

When performing a physical assessment, palpation reveals to the clinic nurse that a client has an enlarged thyroid gland. What action should the nurse take in response to this finding?

Correct Answer is C

Explanation

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