During data collection, the client informed the practical nurse (PN) that the last bowel movement was three days ago. Which actions should the practical nurse (PN) take next? (Select all that apply.)

Rationale:

A. Encourage dangling feet over side of the bed: Dangling the feet increases hydrostatic pressure in the lower extremities and can worsen edema. This intervention is not appropriate for managing pitting edema and could exacerbate fluid accumulation.

B. Enter computer documentation of the finding: Accurately documenting the observed 2+ pitting edema ensures that the client’s current condition is recorded objectively. Documentation allows the healthcare team to track changes over time, evaluate the effectiveness of interventions, and guide further assessment or treatment decisions.

C. Increase the elevation of the feet: Elevating the feet can help reduce edema by promoting venous return, but it is an intervention rather than an initial assessment action. The PN should first document and communicate findings before implementing changes unless directed by a provider.

D. Notify the charge nurse immediately: Immediate notification is warranted if the client’s condition is unstable or worsening. Since the edema has actually decreased from 4+ to 2+, this represents an improvement rather than an urgent deterioration, immediate reporting is not necessary.

Rationale:

A. Give the client an object to hold: Providing an object is not necessary for assessing basic muscle strength and may interfere with accurately evaluating the client’s ability to perform isolated movements. It is more relevant in functional or fine motor assessments rather than strength testing.

B. Palpate the client's muscle tone: Before testing active movements like flexion, the nurse should assess muscle tone through palpation. This allows the PN to detect hypotonia, hypertonia, or spasticity, which can affect strength testing and provide baseline information about neuromuscular function.

C. Instruct the client to close their eyes: Closing the eyes may be useful for assessing proprioception or coordination but is not essential for evaluating basic upper extremity muscle strength. Vision does not significantly impact isolated strength assessment.

D. Apply resistance to the client's arms: Resistance testing occurs after observing the client’s active movement. Applying resistance prematurely could cause discomfort or injury if the nurse has not first assessed baseline tone and voluntary control of the muscles.