Patient Data

During the focused assessment, the practical nurse (PN) notes that the areas are filled with a fluid-like substance.
Which of the following primary skin lesions contain fluid? Select all that apply.

Rationale:

A. Assess level of consciousness: Level of consciousness provides information about neurologic status but does not directly address absent peripheral pulses. While important in overall assessment, it does not help determine the presence or adequacy of blood flow to the extremity.

B. Obtain a doppler stethoscope: Using a Doppler device allows the PN to detect blood flow when a pulse is not palpable by touch. This is a standard follow-up action for assessing peripheral perfusion, particularly in older adults or clients with edema, obesity, or vascular disease that can make palpation difficult.

C. Measure the blood pressure: Blood pressure measurement provides systemic perfusion data but does not identify localized arterial flow to a specific extremity. A normal blood pressure does not rule out peripheral vascular compromise in the foot.

D. Elevate both feet on a pillow: Elevating the extremities may improve venous return but does not aid in locating or confirming an absent dorsalis pedis pulse. This is not effective for evaluating arterial perfusion at the site of concern.

Rationale:

A. Continue by stroking down the medial side of the sole of the foot: Further stroking is unnecessary if the initial test elicited a normal plantar flexion response. Additional stimulation is not required to confirm a normal response and may cause discomfort to the client.

B. Repeat the same motion with the flat portion of the reflex hammer: Using the flat portion is not indicated for testing the plantar reflex. The pointed end is the standard tool for eliciting this response, and repeating the motion is unnecessary when the initial response is normal.

C. Notify the healthcare provider of the presence of a positive Babinski reflex: A positive Babinski reflex is indicated by dorsiflexion of the big toe and fanning of the other toes, which is abnormal in adults. In this patient, the toes curl downward, indicating a normal plantar flexion response; no abnormal finding exists to report.

D. Record the normal response of plantar flexion in the record: The observed downward curling of the toes represents a normal plantar reflex in an adult. Accurate documentation of this normal neurologic finding is the appropriate next step, ensuring continuity of care and baseline assessment for future comparison.