A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record (EMR)?

Circulation impaired.

Paresthesia reported.

Reports feeling "on fire."

Inflammation present.

Answer and Explanation

The Correct Answer is B

A.   This term suggests a problem with blood flow, which could potentially cause symptoms such as numbness or tingling. However, it does not specifically address the sensation of burning. Using this term might lead to an incorrect or incomplete assessment of the client's condition.
B.   Paresthesia is a term used to describe abnormal sensations in the skin, such as burning, tingling, or prickling. The client's report of a burning sensation in the hands and legs aligns well with the definition of paresthesia. Documenting it as "paresthesia reported" accurately reflects the nature of the symptoms and is a medically precise way to describe the abnormal sensory experience.
C.   This documentation uses colloquial language ("on fire") to describe the client's symptoms. While it conveys the intensity of the sensation, it is not a standardized medical term and may not be as clear or useful for clinical documentation.
D.   Inflammation refers to the body's response to injury or infection, which often involves redness, swelling, heat, and pain. The term "inflammation" does not specifically describe the sensation of burning reported by the client.

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Correct Answer is A

Explanation

A. Pain radiating to the neck, jaw, or medial side of the left arm is a classic symptom of an acute myocardial infarction (AMI). This type of referred pain occurs because the heart's pain signals are often perceived in other areas of the body. This finding is a strong indicator of AMI and is consistent with the typical presentation of myocardial infarction.
B. Pain in the anterior thorax that radiates between the scapulae can be associated with various conditions, including myocardial infarction, but it is less specific than pain radiating to the neck, jaw, or arm. While this type of pain can occur in AMI, it is not as distinctive as the classic left arm pain and may also be seen in conditions like angina or musculoskeletal issues.
C. Localized sternal border pain that worsens with palpation is more indicative of a musculoskeletal issue, such as costochondritis, rather than an acute myocardial infarction. AMI typically presents with diffuse chest pain that is not localized or worsened by palpation.
D. Chest pain that worsens with chest movement, such as deep breathing or coughing, is more characteristic of pleuritic pain or musculoskeletal pain rather than an acute myocardial infarction. In AMI, the pain is generally persistent and not influenced by respiratory movements.

A. Hold arms up at 90 degrees while arms are pushed downward. B. Extend arms up to 180 degrees beside the ears. C. Alternate both index fingers to touch the tip of nose accurately. D. Extend arms straight out and hold without drifting.

Correct Answer is B

Explanation

A. This maneuver assesses shoulder strength and endurance but is not a direct measure of the normal range of motion. The test involves resistance but does not provide information on the full range of shoulder movement. It might reveal issues with muscle strength or endurance but does not effectively assess ROM.
B. This assessment technique evaluates shoulder flexion, where the client raises their arms straight up beside the ears, which is a key movement to measure in shoulder ROM. It assesses the ability to lift the arms fully overhead, which is an essential component of shoulder range of motion. This technique directly tests the normal ROM for shoulder flexion and abduction.
C. This maneuver tests coordination and proprioception rather than the range of motion. It is a test for the accuracy of movements and neurological function, particularly useful in assessing cerebellar function, but does not directly measure shoulder ROM.
D. This test assesses shoulder strength and stability rather than range of motion. It is useful for evaluating how well the shoulder can maintain a position but does not provide specific information about the range of motion in different directions.

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A male client reports the onset of a burning sensation in his hands and legs. How should the nurse document this finding in the electronic medical record (EMR)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is B

Explanation

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