To assess a male client's muscle strength, the nurse first asks the client to extend his arms. Before asking the client to flex his arms, what should the nurse do?
Give the client an object to hold.
Instruct the client to close his eyes.
Apply resistance to the client's arms.
Palpate the client's muscle tone.
The Correct Answer is C
Choice A Reason:
Giving the client an object to hold is not the most appropriate action before asking the client to flex his arms to assess muscle strength. While providing an object to hold may engage the muscles, it does not specifically target the muscles involved in arm flexion, which are primarily the biceps brachii and brachialis muscles. Therefore, it may not accurately assess muscle strength during arm flexion.
Choice B Reason:
Instructing the client to close his eyes is not the most appropriate action before asking the client to flex his arms to assess muscle strength. Instructing the client to close his eyes primarily tests proprioception and balance rather than muscle strength. While proprioception is an important aspect of overall neurological function, it is not directly related to assessing muscle strength during arm flexion.
Choice C Reason:
Applying resistance to the client's arms is the most appropriate action before asking the client to flex his arms to assess muscle strength. Applying resistance to the client's arms during flexion allows the nurse to evaluate the client's ability to generate force against resistance, providing a more accurate assessment of muscle strength in the biceps brachii and brachialis muscles.
Choice D Reason:
Palpating the client's muscle tone is not the most appropriate action before asking the client to flex his arms to assess muscle strength. While palpating muscle tone is important for assessing muscle integrity, it does not directly evaluate muscle strength during arm flexion. Muscle tone refers to the resting tension in a muscle and may not accurately reflect muscle strength during active movement.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Choice A Reason
Number of attempts to quit smoking is incorrect. While the number of attempts to quit smoking may provide insight into the client's smoking cessation efforts and motivation, it is not directly relevant to calculating smoking pack years. Pack years specifically quantify the amount and duration of smoking, rather than cessation attempts.
Choice B Reason:
Packs of cigarettes smoked per day is correct. The number of packs of cigarettes smoked per day is a crucial factor in calculating smoking pack years. Pack years are calculated by multiplying the number of packs smoked per day by the number of years the individual has smoked. This information provides a quantitative measure of smoking exposure over time.
Choice C Reason:
Client's current age is incorrect. While the client's current age may be relevant in assessing overall health, risks associated with smoking and in discussing smoking cessation strategies, it is not directly used in the calculation of smoking pack years. Pack years are based on the total duration of smoking and the average daily consumption of cigarettes, not the client's current age.
Choice D Reason:
Number of years the client smoked is correct. The number of years the client has smoked is a critical piece of information for calculating smoking pack years. Pack years are calculated by multiplying the number of packs of cigarettes smoked per day by the number of years the individual has smoked. This helps quantify the duration of smoking history.
Choice E Reason:
Age when the client started smoking is correct. Knowing the age at which the client started smoking is essential for determining the duration of smoking history, which is a key component in calculating pack years. It helps provide a comprehensive understanding of the client's smoking habits and exposure to tobacco smoke over time.
Correct Answer is B
Explanation
Choice A Reason:
An adult male presents with fears that he has "lung cancer." Is appropriate. This choice accurately captures the client's expressed fear of having lung cancer. However, it lacks specificity regarding the duration of symptoms (six weeks) and the nature of the symptom (dry cough). Therefore, while it acknowledges the client's concern, it does not provide comprehensive documentation of the client's reported symptoms.
Choice B Reason:
This option accurately captures the client's primary concern, which is the persistent dry cough lasting for six weeks. It avoids assuming a diagnosis (such as lung cancer) and instead focuses on the client's reported symptom. This type of documentation allows for an objective record of the client's statement while avoiding speculation about specific diagnoses. It also provides important information that can guide further assessment and diagnostic evaluation by healthcare providers.
Choice C Reason:
This option documents the client's expressed concern about having symptoms consistent with lung cancer for the past six weeks. While it accurately reflects the client's fear, it may lead to premature assumptions about the diagnosis before a thorough assessment and diagnostic workup are conducted. It's important for documentation to focus on the client's reported symptoms rather than presumptive diagnoses to maintain objectivity and guide appropriate evaluation and management..
Choice D Reason:
Presents with a hacking non-productive cough of 6 weeks duration. This choice accurately describes the client's reported symptom of a "hacking non-productive cough" and includes the duration of the symptom (six weeks). However, it does not explicitly mention the client's expressed fear of having lung cancer, which is an important aspect of the client's presentation that should be documented. Additionally, the term "hacking" may not fully capture the severity or character of the client's reported cough, as the client described it as "body-wracking." Therefore, while it provides some relevant information, it does not fully capture the client's concerns and presentation.
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