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Question 22Type: MCMAThe nurse is assessing a patient’s gait. Which findings would the nurse consider normal?Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.1. The patient walks with a wide base of support.2. The arms swing according to gait phase.3. The patient shuffles when walking.4. The gait is jerky, with quick movements.5. The patient holds the arms out from the body in slight extension.Correct Answer: 1,2Rationale 1: The patient should walk with a wide base of support to prevent falls.Rationale 2: Coordinated arm swings are considered a normal part of the gait.Rationale 3: A shuffling gait may indicate neurological disorders such as Parkinson’s disease.
Rationale 4: The gait should be smooth and rhythmic, despite speed.Rationale 5: Some neurological disorders are characterized by a slight extension of the arms to maintain balance.Global Rationale: Cognitive Level: ApplyingClient Need: Health Promotion and MaintenanceClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 48-4Question 23Type: MCSAWhen assessing a 68 year-old female patient, the nurse notes an exaggerated curvature of the thoracic spine when the patient bends at the waist. How would the nurse evaluate this finding?1Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 48-5Question 24Type: MCMA
The nurse determines that a patient has pain when turning the hand palm down and then palm up. Which documentation is appropriate?Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.