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 D

Explanation

A. Dimpled area above anus: This can be a sign of a pilonidal cyst, a condition where hair follicles become embedded under the skin.

B. Flap of tissue at sphincter: This could indicate haemorrhoids, swollen veins in the anus and rectum.

C. Hypotonic tone of the anal sphincter: Weak anal sphincter tone can lead to faecal incontinence.

D. Increased pigmentation and coarse skin: This is a normal finding, especially in adults. The perianal area can have a darker colour and thicker skin texture compared to other areas

A. Takes an oral anticoagulant. B. Works in a day care center. C. Adheres to a gluten free diet. D. Recently had dental surgery.

Correct Answer is A

Explanation

A. Takes an oral anticoagulant. Ecchymosis, or bruising, can be a side effect of anticoagulant therapy and may indicate potential bleeding issues that require further assessment.

B. Works in a day care centre. While exposure to children might increase the risk of minor injuries, it is less likely to be directly related to the ecchymosis observed.

C. Adheres to a gluten-free diet. This dietary preference is not likely to be directly related to the ecchymosis observed.

D. Recently had dental surgery. While recent surgery might be relevant, it is less likely to cause widespread ecchymosis unless there were complications.

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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

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

Correct Answer is D

Explanation

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Correct Answer is A

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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?