What is the best way for the nurse to document the assessment of a client's foot on the Admission Database?

Multiple lesions on dorsal aspect of feet probably due to elder abuse

Four burned areas noted on plantar area of each foot

Several partially healed lesions on bottom of left foot, looks like cigarette burns

Four round, 2 cm in diameter lesions on plantar aspect of right foot

Answer and Explanation

The Correct Answer is D

A. Multiple lesions on the dorsal aspect of feet probably due to elder abuse: This option includes a speculative interpretation of the lesions and implies a potential cause (elder abuse) without clear evidence. Speculating about the cause of lesions without proper assessment or confirmation is inappropriate for documentation.

B. Four burned areas noted on the plantar area of each foot: This option describes the finding of burned areas on the plantar area of each foot, but it lacks specificity regarding the size or characteristics of the burns. Additionally, it does not differentiate between the left and right foot. Clarity and precision are important in documentation to ensure accurate communication of findings.

C. Several partially healed lesions on the bottom of the left foot, looks like cigarette burns: While this option provides some details about the location and appearance of the lesions, it lacks specificity regarding the number and size of the lesions. Additionally, it focuses only on the left foot, omitting any findings from the right foot.

D. Four round, 2 cm in diameter lesions on the plantar aspect of the right foot: This is the correct answer. It provides clear and specific details about the findings, including the number, size, and location of the lesions. Using objective descriptors such as "round" and "2 cm in diameter" enhances the clarity of the documentation. Additionally, specifying the location as "plantar aspect of the right foot" ensures accurate communication of the assessment findings.

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

Explanation

A. Support both the client and the family: Nurses have an obligation to support both the client and their family when confronted with an ethical dilemma. This support may involve providing information, facilitating communication, and ensuring that the client's and family's concerns are addressed appropriately.

B. Inform the family and client of nurse's personal beliefs: While nurses may have personal beliefs, it is not ethically appropriate to impose these beliefs on clients or their families. Nurses should maintain professional boundaries and provide care that respects the client's autonomy and values without imposing their own beliefs.

C. Carry out the hospital's policies: Nurses are expected to adhere to the policies and procedures of the healthcare facility where they work. However, if a policy conflicts with ethical principles or legal obligations, nurses should advocate for changes to the policy or escalate the issue through appropriate channels.

D. Refer the issue to the physician since this is not a nurse's responsibility: Nurses have a professional responsibility to address ethical issues within their scope of practice. While collaboration with other healthcare team members, including physicians, is important, nurses should not automatically defer ethical issues to physicians without attempting to address them within their own capacity.

E. Maximize the client's well-being: One of the primary obligations of nurses in ethical dilemmas is to maximize the client's well-being. This includes advocating for the client's rights, providing compassionate care, and promoting the client's best interests while respecting their autonomy and preferences.

A. Jugular vein distention B. Skin turgor, tenting at clavicular area C. Elevated hematocrit D. Oral mucous membranes dry and sticky

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

Explanation

A. Jugular vein distention: Jugular vein distention is not typically associated with deficient fluid volume (dehydration). Instead, it is often seen in conditions of fluid overload, such as heart failure or volume overload. Therefore, this finding is not accurate for deficient fluid volume.

B. Skin turgor, tenting at clavicular area: Skin turgor refers to the skin's ability to return to its normal position after being pinched or pulled. In cases of deficient fluid volume (dehydration), skin turgor is decreased, leading to delayed return of the skin to its normal state. Tenting at the clavicular area is a specific sign of decreased skin turgor and is indicative of dehydration.

C. Elevated hematocrit: Deficient fluid volume (dehydration) leads to hemoconcentration, where there is a relative increase in the proportion of red blood cells to plasma volume. As a result, the hematocrit level, which represents the percentage of red blood cells in the total blood volume, increases. An elevated hematocrit is a laboratory finding commonly associated with deficient fluid volume.

D. Oral mucous membranes dry and sticky: Dehydration can lead to decreased saliva production and dryness of the oral mucous membranes. Dry and sticky oral mucous membranes are common clinical signs of deficient fluid volume (dehydration) and indicate inadequate fluid intake or loss.

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What is the best way for the nurse to document the assessment of a client's foot on the Admission Database?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following is/are nurses' obligation(s) when confronted with an ethical dilemma? (SELECT ALL THAT APPLY)

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

Explanation

The nurse assesses a client with a history of deficient fluid volume. What are the most accurate findings for this fluid volume status? (SELECT ALL THAT APPLY)

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

Explanation

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