When conducting a physical examination of a client with generalized muscle weakness, which of the following is the PRIORITY for the nurse?

Draping body areas that are not being assessed.

Limit position changes as much as possible.

Hand-washing throughout the exam.

Using alcohol swabs to clean the stethoscope.

Answer and Explanation

The Correct Answer is B

Choice a reason:
Draping body areas that are not being assessed is important for maintaining the client's privacy and comfort, but it is not the highest priority when dealing with a client with generalized muscle weakness. The primary concern is to prevent further strain or injury during the examination.

Choice b reason:
Limiting position changes as much as possible is the priority when examining a client with generalized muscle weakness. Frequent or unnecessary movements can cause fatigue, discomfort, and may even be unsafe if the client has severely compromised muscle strength. The nurse should plan the examination to minimize the number of times the client needs to change positions.

Choice c reason:
Hand-washing throughout the exam is a standard practice to prevent the spread of infection. While it is crucial for both the client's and the nurse's safety, in the context of a client with generalized muscle weakness, the priority is to conduct the exam in a way that does not exacerbate the client's condition.

Choice d reason:
Using alcohol swabs to clean the stethoscope before and after the exam is also a standard infection control practice. However, it is not the most immediate concern when prioritizing the steps of a physical examination for a client with muscle weakness.

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Correct Answer is D

Explanation

Choice a reason:
Eye malalignment is a general term that refers to any form of misalignment of the eyes, which can include esotropia but is not specific to it. Esotropia is a type of strabismus where there is a specific pattern of eye malalignment.

Choice b reason:
Eye turning outward is known as exotropia, which is the opposite of esotropia. In exotropia, one or both eyes turn outward away from the nose, which is not characteristic of esotropia.

Choice c reason:
Eye oscillating refers to nystagmus, a condition where the eyes make repetitive, uncontrolled movements, often resulting in reduced vision and depth perception. While nystagmus can occur in conjunction with esotropia, it is not a defining characteristic of esotropia itself.

Choice d reason:
Eye turning inward is the hallmark of esotropia. In this condition, one or both eyes turn inward towards the nose. It can be constant or intermittent and may affect one eye or alternate between both eyes. Esotropia can be comitant, meaning the degree of deviation is the same in every direction of gaze, or incomitant, where the deviation varies with gaze direction.

A. After discussing reactions to allergens. B. After asking about cigarette smoking. C. After reviewing current medications. D. After asking about previous surgeries.

Correct Answer is B

Explanation

Choice A reason:
Discussing reactions to allergens typically focuses on environmental or food triggers that may cause allergic reactions. While it's important to understand a client's allergies, this topic is not closely related to alcohol use, which has different implications for health and lifestyle choices.
Choice B reason:
Asking about alcohol use naturally follows the discussion about cigarette smoking because both involve substance use and have potential health risks. It allows the nurse to transition smoothly from one lifestyle factor to another, which can impact the client's overall health. This approach also helps in creating a comprehensive picture of the client's habits that may contribute to or affect their current health status.
Choice C reason:
Reviewing current medications is an essential part of the health history, as it can reveal potential interactions with alcohol. However, it might be more appropriate to ask about alcohol use after discussing other lifestyle habits such as smoking, as they are more directly related. Once the client's substance use habits are established, the nurse can then discuss how these might interact with prescribed medications.
Choice D reason:
Asking about previous surgeries is important for understanding a client's medical history, but it is not directly related to the client's current lifestyle habits like alcohol use. Therefore, it would be more natural to ask about alcohol use in the context of other substance use discussions rather than after surgical history.

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When conducting a physical examination of a client with generalized muscle weakness, which of the following is the PRIORITY for the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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