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) Anterior to the elbow: This term describes a location in front of the elbow. While it indicates a direction, it does not specifically address the vertical relationship of the discomfort in relation to the elbow. Since the client described discomfort "above" the elbow, this term is not the most accurate choice.
B) Distal to the elbow: The term "distal" refers to a location that is farther away from the trunk of the body or point of reference. Given that the discomfort is described as being above the elbow, this term is incorrect, as it would imply the discomfort is located toward the hand rather than toward the shoulder.
C) Proximal to the elbow: This term correctly indicates a location closer to the trunk of the body and specifically suggests that the discomfort is situated above the elbow, making it the most appropriate medical terminology to use in this context. It accurately reflects the relationship of the discomfort to the elbow.
D) Inferior to the elbow: "Inferior" refers to a location below another point of reference. Since the discomfort is described as above the elbow, this terminology would not apply and would misrepresent the location of the client’s discomfort.
Correct Answer is B
Explanation
A) Avoid hand and foot massages: This statement may not be accurate. Gentle massages can sometimes help with circulation and comfort for individuals with peripheral neuropathy. However, caution should be exercised to avoid injury, as the sensation may be diminished.
B) Use a mirror to inspect feet daily: This is an essential teaching point. Clients with peripheral neuropathy often have decreased sensation in their feet, making it difficult to notice injuries or sores. Using a mirror allows them to check for any signs of injury or changes that could lead to complications, such as infections or ulcers.
C) Increase medication for pain as necessary: While managing pain is important, the client should be advised to consult with their healthcare provider before making any changes to their medication regimen. Self-adjusting medication could lead to unintended side effects or complications.
D) Set the water heater at 120°F: This is not advisable for someone with peripheral neuropathy, as they may not have normal temperature sensation. A lower setting is recommended to prevent burns, as the individual may not feel when the water is too hot.