The nurse asks the patient to dorsiflex and plantarflex both feet against the nurse's hands.
What is the nurse assessing in whole, or part, with this action? Select all that apply.

The strength of the lower extremities.

The patient's sense of balance.

The presence of edema.

The range of motion of the ankle.

The status of the patient's skin turgor.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale:

Assessing the strength of the lower extremities is one of the objectives of asking the patient to dorsiflex and plantarflex both feet against the nurse's hands. This action helps evaluate the muscle strength of the lower limbs, providing information about the patient's neuromuscular function.

Choice B rationale:

Assessing the patient's sense of balance is another objective of this action. Dorsiflexion and plantarflexion require coordination and balance. If the patient struggles to maintain balance while performing these movements, it could indicate issues with proprioception or neurological deficits.

Choice C rationale:

Assessing the presence of edema is not directly related to dorsiflexion and plantarflexion movements. Edema assessment typically involves inspecting and palpating specific areas of the body, such as the ankles, to check for swelling, discoloration, and pitting.

Choice D rationale:

Evaluating the range of motion of the ankle joint is a key aspect of asking the patient to dorsiflex and plantarflex both feet against the nurse's hands. This action allows the nurse to observe how far the patient can move their ankles, providing valuable information about joint flexibility and function.

Choice E rationale:

Assessing the status of the patient's skin turgor involves checking the skin's elasticity and hydration level, usually by pinching and observing how quickly the skin returns to its normal position. This assessment is unrelated to the dorsiflexion and plantarflexion movements and is not applicable in this context.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Choice B rationale:

Isometric exercises involve contracting muscles without changing the length of the muscle or joint angle. In this case, squeezing the gluteal muscles tightly constitutes an isometric exercise. Isometric exercises are often used in rehabilitation settings to strengthen specific muscle groups without putting too much strain on the joints.

Choice A rationale:

Option A describes a range of motion exercise involving the wrist, which is not an isometric exercise. Isometric exercises focus on static muscle contractions, not dynamic movements like circular motions.

Choice C rationale:

Lifting a 5-pound weight to increase arm strength involves isotonic exercise, not isometric exercise. Isotonic exercises involve muscle contractions with movement and changing muscle length, unlike isometric exercises, where muscle length remains constant.

Choice D rationale:

Bending the knee up to the chest is an example of a range of motion exercise and does not constitute an isometric exercise. Range of motion exercises involve moving joints through their full extent, but isometric exercises involve static muscle contractions without joint movement.

A. "I am calling report on Mr. Jones who is being transferred to your unit today from the emergency room.”. B. "He has swelling of the left knee and it is bruised, red and tender. C. "He is requesting a bed close to the bathroom so he can get to the bathroom easier.”. D. "Mr. Jones has had left knee pain following a motor vehicle accident four days ago.”.

Correct Answer is A

Explanation

Choice A rationale:

In the SBAR method, "S" stands for Situation. This portion of the report includes a brief and concise statement about the patient's current situation or problem. In this case, option A provides a clear and specific statement about the patient's situation, indicating that Mr. Jones is being transferred to another unit from the emergency room. The nurse would identify this statement as the "situation" portion of the SBAR report because it conveys the current status of the patient and the reason for the communication.

Choice B rationale:

Option B discusses the patient's symptoms and condition in detail, focusing on the left knee swelling, bruising, redness, and tenderness. While this information is important, it falls under the "Background" section of the SBAR report, not the "Situation" section. The "Situation" section should provide a brief overview of the patient's current status and the reason for the communication, which choice A accurately conveys.

Choice C rationale:

Option C mentions the patient's request for a specific bed location, which is relevant to the patient's preferences but does not constitute the "situation" portion of the SBAR report. This information is more appropriate for the "Recommendation" or "Request" section of the SBAR communication model.

Choice D rationale:

Option D provides information about the patient's history of left knee pain following a motor vehicle accident four days ago. While this information is important for understanding the patient's background, it does not represent the current situation or reason for the communication. Therefore, it does not fit the "situation" portion of the SBAR report.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

The nurse asks the patient to dorsiflex and plantarflex both feet against the nurse's hands.What is the nurse assessing in whole, or part, with this action? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse explains isometric exercises to the patient on the rehabilitation unit.Which explanation provided by the nurse is accurate?

Correct Answer is B

Explanation

A nurse uses the SBAR method to give report about a patient to another unit in the hospital.What statement by the nurse would the nurse identify as the "situation" portion of the SBAR report?

Correct Answer is A

Explanation

The nurse is performing discharge teaching for a patient who has had major abdominal surgery. Which statement or question by the nurse would be appropriate?

The director of nursing reprimands the nursing staff for which violations of HIPAA policy? Select all that apply.

A facility is moving from paper to electronic charting.The nurse manager explains what to be the advantages of electronic charting? Select all that apply.

A nurse is caring for a terminally ill patient during the 2300 to 0700 shift.The patient says, "I just can't go to sleep.I keep thinking about what my family will do when I am gone.”. What response by the nurse would be most appropriate?

The nurse performs range of motion by moving the patient's leg toward the midline of the patient's body.This movement would be documented as what of the hip?

The nurse is instructing a patient about safety with oxygen in the home setting.What would the nurse include in the instructions?

The nurse measures the client's laceration as 5 inches. How many cm would the nurse document as the laceration length? Round to the nearest tenth place.

The nurse is educating a patient about the use of a cane due to weakness of the left leg.Which statement by the patient would indicate teaching has been effective?

The nurse asks the patient to dorsiflex and plantarflex both feet against the nurse's hands.
What is the nurse assessing in whole, or part, with this action? Select all that apply.