A patient states, "I feel like the whole room is spinning around me, and it makes me feel nauseous sometimes." That term will the nurse use to document the patient's symptom?
Dizziness
Tinnitus
Vertigo
Otalgia
The Correct Answer is C
A) Dizziness: While the term "dizziness" can describe a range of sensations, it is more general and does not specifically capture the experience of the patient feeling that the room is spinning. Dizziness can include feelings of lightheadedness or imbalance, which are not the primary symptoms the patient is describing.
B) Tinnitus: Tinnitus refers to the perception of sound, such as ringing or buzzing, in the absence of an external source. This term does not relate to the patient's symptoms of spinning sensations and nausea, making it irrelevant in this context.
C) Vertigo: This term accurately describes the sensation of spinning or movement, often associated with inner ear disturbances. The patient's description aligns with vertigo, as it reflects the specific experience of feeling as though the environment is moving, which can indeed lead to nausea.
D) Otalgia: Otalgia refers to ear pain and is not applicable to the symptoms the patient describes. Since the patient is focusing on a spinning sensation and associated nausea, this term does not relate to the presenting issue.
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Correct Answer is C
Explanation
A) +10: This score does not exist on the muscle function grading scale, which typically ranges from 0 to 5. Using +10 could confuse the assessment and misrepresent the client's strength.
B) +4: This score indicates good strength against some resistance but not full strength. It suggests that the client has nearly complete function but may still have some limitations in range or strength.
C) +5: This score signifies full muscle strength and complete range of motion in a joint without any limitations. A score of +5 is what you would expect for a client demonstrating full strength, indicating optimal muscle function.
D) +1: This score indicates trace muscle contraction with minimal movement, which is far from the full strength described in the question. It suggests severe weakness and would not apply in this case.
Correct Answer is B
Explanation
A) This would indicate pitting edema: Tenting is not indicative of pitting edema, which is characterized by a depression left in the skin after pressure is applied. Tenting specifically refers to the skin's elasticity and is assessed by pinching the skin, observing how quickly it returns to its normal position.
B) This may indicate dehydration, but might not be reliable in an older adult: Tenting is often a sign of dehydration, as it reflects decreased skin elasticity. However, in elderly individuals, skin changes due to aging (like reduced elasticity and moisture) may make this assessment less reliable. Factors such as medications, health status, and overall skin integrity can also influence this observation, making it necessary to consider other indicators of hydration.
C) This means the client is well hydrated: Tenting does not indicate adequate hydration. In fact, it typically suggests the opposite, as well-hydrated skin should return to normal quickly after being pinched.
D) This indicates peripheral neuropathy: While peripheral neuropathy can affect skin and tissue integrity, tenting specifically relates to skin turgor and elasticity rather than nerve function. Tenting is not a direct indicator of neuropathy; other assessments would be needed to evaluate nerve health.