While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

Perform passive range of motion and compare the findings.

Compare measured circumferences of each extremity joint.

Instruct client to walk across room and observe the gait.

Measure the length of each leg and document the findings.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Performing passive range of motion and compare the findings is inappropriate. While assessing passive range of motion can provide information about joint mobility and flexibility, it may not directly address the asymmetry observed in the legs. Range of motion assessment is more relevant for evaluating joint function and flexibility rather than leg length asymmetry.
Choice B Reason:
Comparing measured circumferences of each extremity joint is inappropriate. Measuring circumferences of extremity joints may help identify differences in muscle mass or swelling, but it may not directly address the asymmetrical leg length observed. Circumference measurements are more relevant for assessing muscle bulk or detecting signs of edema rather than leg length asymmetry.
Choice C Reason:
Instructing client to walk across the room and observe the gait is inappropriate. Observing the client's gait can provide valuable information about their walking pattern and any abnormalities in movement. While an abnormal gait may be associated with leg length asymmetry, directly measuring leg length would provide more precise data for evaluation.
Choice D Reason:
Measuring the length of each leg and document the findings is appropriate. Measuring the length of each leg can help identify any significant differences in leg length, which could be contributing to the asymmetry observed. Leg length discrepancy can result from various musculoskeletal conditions such as scoliosis, hip dysplasia, or unequal growth rates. Documenting the findings allows for accurate tracking of changes over time and provides important information for healthcare providers to determine appropriate interventions, such as orthotic devices or physical therapy.

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Correct Answer is A

Explanation

Choice A Reason:
Requesting diagnostic laboratory testing for the client is appropriate action. Enlargement of the thyroid gland can be indicative of various thyroid disorders, including hyperthyroidism, hypothyroidism, or thyroid nodules. Diagnostic laboratory testing, such as thyroid function tests (TFTs), thyroid antibody testing, and possibly thyroid ultrasound, can help identify the underlying cause of the thyroid enlargement. These tests can include assessments of thyroid hormone levels (T3, T4, and TSH), antibodies, and imaging studies. Requesting diagnostic laboratory testing is essential to accurately diagnose the condition and guide appropriate management and treatment.
Choice B Reason:
Obtaining a dietary consultation for nutrition teaching is inappropriate action. While nutrition can play a role in overall thyroid health, obtaining a dietary consultation for nutrition teaching is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Dietary consultation may be considered as part of comprehensive care for thyroid disorders, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.
Choice C Reason:
Instructing the client in the need to use iodized salt is inappropriate action. While iodine deficiency can contribute to thyroid disorders, instructing the client to use iodized salt is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Using iodized salt may help prevent iodine deficiency, but it does not address the need for further evaluation and diagnosis of the thyroid enlargement.
Choice D Reason:
Scheduling a follow-up appointment in one month is inappropriate action. While scheduling a follow-up appointment may be necessary for ongoing monitoring and management of thyroid disorders, it is not the most immediate action to take in response to finding an enlarged thyroid gland during palpation. Further evaluation and diagnostic testing should be prioritized to determine the underlying cause of the thyroid enlargement and initiate appropriate treatment.

A. Cover the inflamed area and notify the healthcare provider. B. Auscultate the lymph node for the presence of a bruit. C. Ask the client about any localized tenderness at the site. D. Record this normal finding in the assessment record.

Correct Answer is C

Explanation

Choice A Reason:
Covering the inflamed area and notify the healthcare provider suggests taking precautions to protect the inflamed area and promptly informing the healthcare provider. While it's important to notify the healthcare provider about any concerning findings, covering the area without further assessment may prevent the nurse from gathering additional information that could be helpful in determining the cause of the lymph node enlargement.
Choice B Reason:
Auscultating the lymph node for the presence of a bruit involves listening for abnormal sounds (bruits) over the lymph node, which could indicate underlying vascular abnormalities. While it's important to assess lymph nodes for abnormalities, such as tenderness or enlargement, auscultation for bruits is not a standard assessment technique for lymph nodes.
Choice C Reason:
Asking the client about any localized tenderness at the site involves directly gathering information from the client about their experience of tenderness at the site of the enlarged lymph node. This information can provide valuable clues about the nature of the lymph node enlargement, such as whether it is inflamed due to infection or inflammation.
Choice D Reason:
Recording this normal finding in the assessment record assumes that the nurse considers the enlarged and visible lymph node as a normal finding. However, enlarged and visible lymph nodes are not typically considered normal and may indicate an underlying health issue that requires further assessment and intervention.

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While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

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Naxlex Comprehensive Predictor Exams

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 A

Explanation

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Correct Answer is C

Explanation

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