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 B

Explanation

A. Chronic Obstructive Pulmonary Disease (COPD) can lead to decreased lung function and abnormalities in lung expansion. However, COPD typically results in a more generalized decrease in lung expansion and breath sounds, rather than pronounced unilateral inequality. While COPD can cause irregularities in lung expansion, it is less likely to cause significant unilateral differences in lung expansion.
B. Unequal lung expansion is a key sign of a collapsed lung, or pneumothorax. When a lung collapses, the affected side will show reduced or absent expansion compared to the unaffected side. This is because the collapsed lung cannot expand properly during inhalation, leading to noticeable differences in breath sounds and lung movement on physical examination.
C. If the client's lungs were functioning normally, one would expect to observe symmetrical lung expansion. Unequal lung expansion is not a normal finding and usually indicates some form of pathology or abnormality in the lung or thoracic cavity. Normal lung function should result in even expansion of both lungs.
D. Chronic lung infections, such as tuberculosis or severe pneumonia, might cause abnormalities in lung sounds or localized lung issues, but they are less likely to cause pronounced unilateral differences in lung expansion. While they can affect lung function, they typically do not cause the same degree of unilateral expansion issues as a pneumothorax would.

A. Observe chest and upper neck for a rash. B. Evaluate for a loss of peripheral vision. C. Assess deep tendon reflexes. D. Perform a hearing test.

Correct Answer is D

Explanation

A. Observing the chest and upper neck for a rash is not directly relevant to assessing tinnitus. Tinnitus is an auditory condition, and a rash in these areas would not typically provide information about the presence or effects of tinnitus. This option is not suitable for evaluating tinnitus.
B. Evaluating for a loss of peripheral vision is related to visual assessments rather than auditory conditions. Peripheral vision loss does not provide direct information about tinnitus or its effects. This option is not relevant to assessing the impact of tinnitus.
C. Assessing deep tendon reflexes is a neurological examination that helps evaluate the functioning of the nervous system but does not provide information about tinnitus. Tinnitus is related to auditory perception and not directly assessed through reflexes.
D. Performing a hearing test is directly relevant to evaluating tinnitus. Tinnitus often accompanies hearing loss or auditory dysfunction. A hearing test can help determine if there is a hearing impairment or other auditory issues associated with tinnitus.

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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

When assessing an adult client, the nurse notes that the client has unequal lung expansion. Which conclusion regarding this finding is most likely to be accurate?

Correct Answer is B

Explanation

In reading a client's record, the nurse notes that the client is experiencing tinnitus. Which assessment provides the nurse with the information needed to evaluate the effects of this condition?

Correct Answer is D

Explanation

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