The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer?

Compare the skin turgor of the client's upper and lower leg.

Observe the specific location and appearance of the ulceration.

Note any change in the color of the ulcer when the leg is moved.

Measure the degree of joint range of motion in the extremity.

Answer and Explanation

The Correct Answer is B

A. Skin turgor assesses skin elasticity and hydration, which is more indicative of general hydration status rather than specific types of insufficiency. While poor skin turgor might be observed in various conditions, it does not specifically differentiate between venous and arterial ulcers.
B. The location and appearance of the ulcer can provide significant clues about its etiology. Venous ulcers often appear on the lower legs, particularly around the medial malleolus (inside of the ankle), and tend to have irregular, shallow, and often wet or weepy edges.
C. Changes in color upon movement can provide insight into the type of insufficiency. For arterial ulcers, the leg may appear pale or blanched when elevated and may develop a reddish or purple color when lowered due to poor blood flow.
D. Measuring joint range of motion assesses flexibility and mobility rather than the type of ulcer. While joint mobility issues can be associated with various conditions, including those affecting the vascular system, it does not directly help in distinguishing between venous and arterial insufficiency ulcers.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"D"},"B":{"answers":"B"}}

Explanation

Wrist: Able to bend wrist back toward forearm

Flexion: When the wrist bends back toward the forearm, it is an example of flexion. Flexion decreases the angle between the wrist and the forearm.

Elbow: Only able to straighten joint 30 degrees

Extension: The ability to straighten the elbow is indicative of extension. In this case, the client is only able to straighten the elbow to 30 degrees, which reflects limited extension.

A. Auscultate all quadrants of the client's abdomen. B. Inspect the area around the client's umbilicus. C. Lightly palpate areas of abdominal protuberance. D. Observe the appearance of the client's stool.

Correct Answer is D

Explanation

A. Auscultation of the abdomen involves listening to bowel sounds and can provide information about the gastrointestinal system's activity, such as whether there is increased or decreased motility. While important for assessing general bowel function, auscultation is not specific for confirming steatorrhea. It does not provide direct information about the presence of fat in the stool.
B. Inspecting the area around the umbilicus may help in identifying other abdominal conditions, such as hernias or signs of ascites. However, it does not provide information about stool characteristics or fat content, so it is not the most appropriate action for confirming steatorrhea.
C. Light palpation of areas of abdominal protuberance can help assess for abdominal masses or tenderness. While palpation can provide useful information about the abdominal organs and possible fluid accumulation, it does not give information about stool fat content.

D. Observing the appearance of the client’s stool is the most direct method to confirm steatorrhea. Stool that is greasy, foul-smelling, and floats is characteristic of steatorrhea, indicating the presence of undigested fat. This observation directly assesses the presence of fat in the stool, making it the best action to confirm steatorrhea.

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The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Patient Data Exhibits

Correct Answer is {"A":{"answers":"D"},"B":{"answers":"B"}}

Explanation

To confirm the presence of steatorrhea, which action should the nurse take?

Correct Answer is D

Explanation

In assessing a client's nailbeds, the nurse notes that the angle between the nail and the nailbed is 200 degrees. Which action should the nurse take?

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