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.
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Maintaining the patient in a supine position during rest would not be appropriate for a client with shortness of breath. This position can worsen breathing difficulties, especially in clients with respiratory issues. It reduces lung expansion and can lead to increased work of breathing.
Choice B rationale:
Monitoring the client's oxygen saturation hourly is the appropriate intervention for a client with shortness of breath. Oxygen saturation (SpO2) levels indicate the percentage of oxygen bound to hemoglobin in the blood. Monitoring SpO2 levels helps assess the client's oxygenation status and provides crucial information about the effectiveness of respiratory interventions. Normal oxygen saturation levels typically range between 95% to 100%. Monitoring allows timely recognition of hypoxemia, enabling prompt intervention to improve oxygenation and prevent complications.
Choice C rationale:
Ambulating the client in the hall four times daily may not be suitable for a client experiencing shortness of breath, as it can exacerbate respiratory distress. Ambulation increases oxygen demand and can further compromise oxygenation in individuals struggling to breathe.
Choice D rationale:
Encouraging high protein foods during mealtime is unrelated to the immediate management of shortness of breath. While proper nutrition is essential for overall health and healing, it does not directly address the acute issue of respiratory distress.
Correct Answer is D
Explanation
Choice A rationale:
Permitting smoking in the home, even with low-flow oxygen, is highly dangerous and increases the risk of fire. Oxygen supports combustion, and any open flames, including smoking materials, can lead to a catastrophic fire. Therefore, this option is incorrect and unsafe.
Choice B rationale:
Placing the oxygen tank in direct sunlight is not advisable. Oxygen tanks should be stored in cool, well-ventilated areas away from direct sunlight, heat sources, and flammable materials. Storing the tank in direct sunlight can increase the pressure inside the tank, potentially leading to leaks or ruptures.
Choice C rationale:
Encouraging the patient to use electric razors is a safe practice when wearing oxygen. Electric razors eliminate the risk of open flames, reducing the potential for accidents. This option promotes patient safety and is a suitable instruction for patients using oxygen at home.
Choice D rationale:
Not using electrical equipment near the oxygen administration set is crucial for patient safety. Electrical equipment can generate sparks, posing a significant fire hazard in the presence of oxygen. Instructing patients to keep electrical devices away from oxygen supplies helps prevent accidents and ensures a safe home environment for patients requiring oxygen therapy.
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