During report, the practical nurse (PN) is told that a client has 4+ pitting edema of both feet and ankles. The PN observes the client's lower extremities and finds 2+ pitting edema bilaterally. Which action should the PN take?

Encourage dangling feet over side of the bed.

Enter computer documentation of the finding.

Increase the elevation of the feet.

Notify the charge nurse immediately.

Answer and Explanation

The Correct Answer is B

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.

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Correct Answer is C

Explanation

Rationale:

A. Request the client to reach for a spoon on the breakfast tray: Reaching for objects evaluates coordination and fine motor skills more than gross muscle strength. While it can provide some information, it is not a standardized or reliable method to assess upper extremity strength.

B. Tell the client to touch themself on the nose with a forefinger 5 times: This maneuver, known as the finger-to-nose test, assesses coordination, proprioception, and cerebellar function. It does not provide an accurate measure of muscle strength in the upper extremities.

C. Have the client use both hands to grip and squeeze the PN's hands: Handgrip strength testing is a direct, objective method to evaluate upper extremity muscle strength. By having the client squeeze the PN’s hands, the nurse can compare bilateral strength and identify weakness that may indicate neurologic impairment following a TIA.

D. Ask the client to extend both arms to the side and move in small to larger circles: This movement tests range of motion and coordination rather than strength. It is useful for assessing motor control but does not quantify or reveal muscle weakness effectively.

A. Status of current appetite. B. A 24 hour diet history. C. Condition of hair, nails, and skin. D. History of a recent weight loss.

Correct Answer is C

Explanation

Rationale:

A. Status of current appetite: While appetite provides insight into recent food intake and potential acute changes, it is a subjective and short-term indicator. Appetite alone does not accurately reflect overall nutritional status or the presence of chronic deficiencies.

B. A 24 hour diet history: A 24-hour recall offers a snapshot of recent dietary intake but may not represent typical eating patterns. It also may be influenced by recall bias, making it insufficient as a standalone measure of nutritional status.

C. Condition of hair, nails, and skin: Physical examination of hair, nails, and skin provides objective evidence of long-term nutritional status. Signs such as brittle nails, hair thinning, or dry, scaly skin can indicate deficiencies in protein, vitamins, or minerals, making these findings reliable indicators of overall nutrition.

D. History of a recent weight loss: Recent weight loss can signal malnutrition or illness but does not provide detailed information about nutrient intake or deficiencies. It must be considered alongside physical signs and dietary history to fully evaluate nutritional status.

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During report, the practical nurse (PN) is told that a client has 4+ pitting edema of both feet and ankles. The PN observes the client's lower extremities and finds 2+ pitting edema bilaterally. Which action should the PN take?

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