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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is C

Explanation

Choice a reason:
The left temporal bone would be the expected site of lateralization for sound in a Weber test if the patient had conductive hearing loss in the left ear. However, with unilateral sensorineural hearing loss, the sound typically lateralizes to the opposite ear, which is the ear with better hearing.
Choice b reason:
Lateralization to both ears equally during the Weber test would suggest either normal hearing or symmetrical hearing loss. In the case of unilateral sensorineural hearing loss, the sound is not perceived as equal in both ears because the affected ear does not hear as well as the unaffected ear.
Choice c reason:
In a patient with unilateral sensorineural hearing loss in the left ear, the Weber test will lateralize to the right ear, which is the ear with normal hearing. This occurs because the inner ear on the affected side is not able to transmit the sound as effectively as the unaffected side, making the sound seem louder in the ear with better hearing.
Choice d reason:
Lateralization to the left ear in the Weber test would indicate conductive hearing loss in the left ear, not sensorineural hearing loss. In sensorineural hearing loss, the sound vibrates to the ear with better cochlear function, which would be the right ear in this case.

A. Reddened intact skin. B. Skin loss involving up to the subcutaneous tissue (fat). C. Skin loss involving up to the dermis layer. D. Exposed bone.

Correct Answer is B

Explanation

Choice A reason:

Reddened intact skin is typically associated with a stage 1 pressure ulcer, where the skin is not yet broken but shows signs of redness. This stage indicates that the skin is under pressure and may be at risk for further breakdown if the pressure is not relieved.

Choice B reason:

A stage 3 pressure ulcer involves full-thickness skin loss that extends into the subcutaneous tissue layer but does not involve underlying muscle or bone. The ulcer presents as a deep crater, and there may be slough or eschar present. It is important to manage these ulcers carefully to prevent further deterioration and complications such as infection.

Choice C reason:

Skin loss involving up to the dermis layer is characteristic of a stage 2 pressure ulcer. In this stage, the epidermis and part of the dermis are lost, creating a shallow open wound or blister. This stage is less severe than stage 3 and requires different management strategies to promote healing and prevent progression.

Choice D reason:

Exposed bone is indicative of a stage 4 pressure ulcer, which is the most severe stage. It involves full-thickness skin loss with extensive destruction, possibly including muscle, tendon, or bone exposure. These ulcers are at high risk for serious infections, including osteomyelitis, and require aggressive medical and surgical intervention to heal.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

A patient is diagnosed with left ear unilateral sensorineural hearing loss. During the performance of the Weber test, the nurse expects lateralization of the sound/vibration to the:

Correct Answer is C

Explanation

A nurse is assessing a client who has a pressure ulcer. The nurse should recognize which of the following findings is a manifestation of a stage 3 pressure ulcer?

Correct Answer is B

Explanation

Prior to completing the physical examination of a patient post motor vehicle crash, the ER nurse determines that the client is awake, alert, and oriented. This information would be important for which part of the general survey?

The nurse working in an ophthalmology clinic is preparing to assess a patient's near vision. Which piece of equipment would the nurse use for this assessment?

A client describes a 3-week history of hoarseness. The client also reports feeling fatigue and noticeable weight gain over the past month. Which cause should the nurse consider as most likely?

Which of the following should the nurse do before conducting a physical examination of a client? (Select all that apply)

A nurse prepares an educational session on the importance of oral hygiene. Which teaching tip should be included in the section about preventing gingivitis?

During a comprehensive health history, a client reports coming into the hospital because he "feels like an elephant is sitting on his chest." The nurse will document this information in which of the following sections?

A nurse is assessing a client who has myxedema. Which of the following findings should the nurse expect?

The nurse working in an outpatient GI clinic is conducting a physical examination of the abdomen. What is the nurse's best action to ensure she can hear bowel sounds?