When assessing an ambulatory patient, the nurse observes that both arms swing freely in alternation with leg swings. Which of the following is being assessed?
Muscle strength
Gait
Alignment
Joint function
The Correct Answer is B
A) Muscle strength: While muscle strength can influence gait, it specifically refers to the ability of muscles to exert force against resistance. Assessing muscle strength involves different techniques, such as manual muscle testing, rather than observing arm and leg movements.
B) Gait: The observation that both arms swing freely in alternation with leg swings is a direct assessment of the patient's gait. A normal gait pattern includes coordinated movements of the arms and legs, indicating proper motor function and balance.
C) Alignment: This term refers to the positioning of the body and its parts in relation to one another. While alignment can impact gait, it is not specifically assessed by observing the movement of the arms and legs.
D) Joint function: Joint function assessment typically focuses on the range of motion, stability, and mobility of individual joints. Observing the swing of arms and legs provides insight into overall gait rather than specific joint function.
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Correct Answer is C
Explanation
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.
Correct Answer is ["A","C","D","E"]
Explanation
A) Impact on ADLs: Understanding how pain affects a client's activities of daily living (ADLs) is crucial for assessing the overall impact of the pain on their life. It provides insight into the functional limitations caused by the pain and helps guide treatment planning.
B) Family medical history: While family medical history can provide context for certain conditions, it is not an essential component of a focused pain assessment. The immediate concerns are more directly related to the client's current pain experience rather than their family's medical background.
C) Pain intensity rating: Assessing the intensity of pain is a fundamental aspect of pain assessment. Using scales (e.g., 0-10) allows the nurse to quantify the pain, monitor changes over time, and evaluate the effectiveness of interventions.
D) Characteristics of the pain: Understanding the characteristics of the pain—such as its quality (sharp, dull, throbbing) and location—is essential for determining its cause and guiding appropriate treatment strategies.
E) Aggravating factors: Identifying what exacerbates the pain is critical for understanding its nature and developing effective management strategies. Knowing which activities or positions worsen the pain can help in creating a comprehensive care plan tailored to the client's needs.