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 C
Explanation
Choice C rationale:
When a patient has been bedridden for an extended period, such as two weeks, the nurse expects to find atrophy of leg muscles due to immobility. Lack of physical activity leads to muscle wasting, which can result in decreased muscle mass and strength. This condition is reversible with proper rehabilitation and exercise.
Choice A rationale:
Decreased respiratory rate due to stronger lungs is not a typical effect of immobility. Immobility can lead to decreased lung expansion and increased risk of respiratory complications, such as pneumonia.
Choice B rationale:
Increased urinary output due to enhanced bladder muscle tone is not a direct effect of immobility. Immobility can affect urinary elimination, but it is more likely to cause urinary retention due to decreased mobility and inability to reach the bathroom independently.
Choice D rationale:
Frequent bowel movements due to increased peristalsis are not expected with immobility. Immobility often leads to slowed peristalsis, which can result in constipation rather than frequent bowel movements.
Correct Answer is B
Explanation
Choice A rationale:
Statements provided by the patient's family are not a reliable defense against nursing negligence. While family statements can offer context, they may not always be accurate or objective. Legal defenses require concrete evidence and accurate documentation.
Choice B rationale:
Accurate documentation by the nurse is the best defense against allegations of nursing negligence. Thorough and precise documentation provides a clear account of the patient's condition, the care provided, and the patient's response. Proper documentation is essential for legal and ethical reasons and serves as a valuable defense in case of legal disputes.
Choice C rationale:
Testimony of other nurses may support the case but may not be as reliable as accurate documentation. Nurse testimony can be subjective and may vary, making it less robust as a defense compared to comprehensive and detailed documentation.
Choice D rationale:
Inclusion of expert witnesses can be helpful, but their testimony is most effective when combined with accurate documentation. Expert witnesses can provide specialized knowledge and opinions, but their credibility is enhanced when supported by thorough and precise nursing documentation.
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