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    Hesi rn health assessment proctored exam (retest)

    In completing a physical assessment of a young adult, the clinic nurse observes muscular atrophy of the right thigh and calf. To gather additional data related to this finding, which action should the nurse take?

    Explanation & Rationale

    Rationale: A. Obtain vital signs and oxygen saturation: While vital signs and oxygen saturation provide essential information about cardiovascular and respiratory status, they do not directly assess or explain localized muscle atrophy, which points more toward a musculoskeletal or neurologic issue. B. Calculate the body mass index (BMI): BMI evaluates overall body weight relative to height and can identify underweight, overweight, or obesity. However, it does not provide specific information about asymmetrical muscle wasting or localized muscle function. C. Measure degree of skin elasticity: Skin elasticity assessment is useful for hydration status but is unrelated to muscular strength or the presence of atrophy. It would not offer meaningful information about the function or cause of the observed muscle changes. D. Compare muscle strength bilaterally: Comparing muscle strength on both sides allows the nurse to assess for weakness, nerve impairment, or disuse atrophy. This focused and direct examination is essential to determine the extent and functional impact of the observed muscle wasting.

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