The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)?

Appears confused and depressed.

Demonstrates signs of early dementia.

Ambulatory and disoriented to place.

Wandering behavior with flat affect.

Answer and Explanation

The Correct Answer is D

Choice A Reason:
Appears confused and depressed is incorrect. This option includes subjective interpretations ("confused" and "depressed") that may not accurately reflect the observed behavior. It's important to avoid subjective assessments and stick to objective descriptions of the client's behavior and mental status.
Choice B Reason:
Demonstrates signs of early dementia is incorrect. This option jumps to a diagnostic label ("early dementia") based on the observed behavior, which is not appropriate without further assessment and evaluation by a healthcare provider specializing in geriatric care or neurology. It's crucial to avoid diagnosing conditions based solely on observations without proper evaluation.
Choice C Reason:
While the client is ambulatory, the term "disoriented to place" is an assumption that has not been explicitly confirmed through an assessment. The documentation should be based on observable facts rather than assumptions.
Choice D Reason:
This statement is accurate, objective, and based on observable behaviors. "Wandering behavior" describes the client's aimless walking, and "flat affect" refers to the blank expression. This documentation does not make assumptions about the client's mental state beyond what is directly observable.

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Correct Answer is ["A","B","C"]

Explanation

Choice A Reason:
Jugular venous distension is correct. Jugular venous distension is a common sign of fluid overload and increased central venous pressure, which occur during exacerbations of heart failure. It indicates impaired cardiac function and elevated systemic venous pressure.
Choice B Reason:
Peripheral edema is correct. Peripheral edema, particularly in the lower extremities, is a classic manifestation of fluid retention and congestion in heart failure exacerbations. It results from increased capillary hydrostatic pressure and impaired fluid reabsorption by the kidneys.
Choice C Reason:
Dyspnea is correct. Dyspnea, or shortness of breath, is a hallmark symptom of heart failure exacerbations. It occurs due to pulmonary congestion resulting from fluid accumulation in the lungs, impairing gas exchange and leading to difficulty breathing.
Choice D Reason:
Intercostal retraction is not typically associated with exacerbations of heart failure. Intercostal retractions indicate increased work of breathing and respiratory distress, which may occur in conditions such as severe respiratory infections or asthma exacerbations, but are not specific to heart failure exacerbations.
Choice E Reason:
Headaches are not typically associated with exacerbations of heart failure. Headaches can have various causes, including tension, migraines, or sinus congestion, but they are not commonly observed as a direct manifestation of heart failure exacerbations.

A. Perform passive range of motion and compare the findings. B. Compare measured circumferences of each extremity joint. C. Instruct client to walk across room and observe the gait. D. Measure the length of each leg and document the findings.

Correct Answer is D

Explanation

Choice A Reason:
Performing passive range of motion and compare the findings is inappropriate. While assessing passive range of motion can provide information about joint mobility and flexibility, it may not directly address the asymmetry observed in the legs. Range of motion assessment is more relevant for evaluating joint function and flexibility rather than leg length asymmetry.
Choice B Reason:
Comparing measured circumferences of each extremity joint is inappropriate. Measuring circumferences of extremity joints may help identify differences in muscle mass or swelling, but it may not directly address the asymmetrical leg length observed. Circumference measurements are more relevant for assessing muscle bulk or detecting signs of edema rather than leg length asymmetry.
Choice C Reason:
Instructing client to walk across the room and observe the gait is inappropriate. Observing the client's gait can provide valuable information about their walking pattern and any abnormalities in movement. While an abnormal gait may be associated with leg length asymmetry, directly measuring leg length would provide more precise data for evaluation.
Choice D Reason:
Measuring the length of each leg and document the findings is appropriate. Measuring the length of each leg can help identify any significant differences in leg length, which could be contributing to the asymmetry observed. Leg length discrepancy can result from various musculoskeletal conditions such as scoliosis, hip dysplasia, or unequal growth rates. Documenting the findings allows for accurate tracking of changes over time and provides important information for healthcare providers to determine appropriate interventions, such as orthotic devices or physical therapy.

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The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An older adult client with a history of heart failure (HF) is brought to the clinic by a family member. Which finding(s) confirm to the nurse that the client is experiencing an exacerbation of the HF? Select all that apply.

Correct Answer is ["A","B","C"]

Explanation

While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?

Correct Answer is D

Explanation

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