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 A
Explanation
Choice A rationale:
In the SOAP format used for medical documentation, "P" stands for Plan. The "P" portion of the note includes the healthcare provider's plan for the patient, which may involve treatments, medications, or other interventions. Option A discusses the patient's ability to walk unassisted, feelings of safety while ambulating, and plans for discharge home in 3 days. This information represents the provider's plan for the patient's care and fits the "P" portion of the SOAP note.
Choice B rationale:
Option B describes the patient's physical examination findings related to range of motion and reflexes in the lower extremities. This information falls under the "Objective" section of the SOAP note, which includes observable and measurable data. While important for the overall patient assessment, it does not represent the provider's plan for the patient's care (the "P" portion of SOAP).
Correct Answer is D
No explanation
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