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A student nurse documents the following: Lower left leg cool, mild edema, with dorsalis pedis, posterior knee and femoral pulse normal. How should this documentation be charted to communicate the assessment using appropriate medical terminology?

Left extremity cool to touch, normal pitting edema, with femoral, posterior tibial, and dorsalis pedis pulses palpable, +2.

Left lower extremity cool to touch, +2 pitting edema, with femoral, popliteal, and dorsalis pedis pulses palpable, +2.

Left lower leg cool to touch, +4 edema with femoral, posterial tibial, dorsalis and pedis pulses normal.

Left lower leg normal cool temperature, slight swelling, femoral, posterior tibial and dorsalis pedis pulses normal.

Answer and Explanation

The Correct Answer is B

A) Left extremity cool to touch, normal pitting edema, with femoral, posterior tibial, and dorsalis pedis pulses palpable, +2: While this option describes the left extremity and includes some relevant details, it inaccurately uses "normal pitting edema" without specifying the degree of edema clearly. Additionally, it lists the posterior tibial pulse instead of the popliteal, which is more appropriate given the anatomical location.

B) Left lower extremity cool to touch, +2 pitting edema, with femoral, popliteal, and dorsalis pedis pulses palpable, +2: This documentation accurately describes the left lower extremity, specifies the degree of edema as "+2," and correctly identifies the relevant pulses as femoral, popliteal, and dorsalis pedis. This terminology is clear and concise, providing a comprehensive assessment of the vascular status.

C) Left lower leg cool to touch, +4 edema with femoral, posterial tibial, dorsalis and pedis pulses normal: This option incorrectly reports the degree of edema as "+4," which indicates severe swelling, not matching the original assessment of "mild edema." It also incorrectly lists the posterior tibial pulse, which should be popliteal.

D) Left lower leg normal cool temperature, slight swelling, femoral, posterior tibial and dorsalis pedis pulses normal: The term "normal cool temperature" is confusing and not standard terminology. Additionally, "slight swelling" lacks specificity regarding the degree of edema, which is important for a clinical assessment. Furthermore, it inaccurately refers to the posterior tibial pulse instead of the popliteal.

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Correct Answer is A

Explanation

A) "What can we do to accommodate your needs during your stay here?" This response is the most appropriate as it demonstrates cultural sensitivity and respect for the client’s religious practices. It opens the door for a collaborative discussion about how the healthcare team can support the client’s fasting while ensuring that his health needs are met during hospitalization.

B) "I will let your healthcare provider know that you need to be discharged." While it is important to communicate the client’s needs to the healthcare provider, suggesting discharge may not be a feasible solution. It does not address the complexities of fasting during hospitalization and could imply that the client’s faith is a burden rather than a respected aspect of their care.

C) "Fasting may be harmful to your body during your illness." While it is crucial to ensure the client’s health is not compromised, this response could come off as dismissive of the client’s beliefs. Instead of expressing concern, it could be more beneficial to explore how fasting can be managed within the context of their medical care.

D) "You must eat a high protein diet during times of illness." This response does not take into account the client’s religious beliefs and fails to respect the significance of fasting in the Muslim faith. While dietary considerations are important, this approach disregards the client’s right to practice their faith and may come across as prescriptive rather than collaborative.

A. Muscle strength B. Gait C. Alignment D. Joint function

Correct Answer is B

Explanation

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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A student nurse documents the following: Lower left leg cool, mild edema, with dorsalis pedis, posterior knee and femoral pulse normal. How should this documentation be charted to communicate the assessment using appropriate medical terminology?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is admitting a client of the Muslim faith during the holy month of Ramadan. The client tells the nurse that he must fast during this time. Which response by the nurse is the most appropriate?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

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