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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Be available to the client: This is the most appropriate action for the nurse to take. The client's question reflects existential distress and a search for meaning in the face of suffering. Being available to listen to the client's concerns, offering emotional support, and providing a safe space for the client to express their feelings can be comforting and therapeutic. The nurse should demonstrate empathy, validate the client's emotions, and encourage open communication without imposing personal beliefs or judgments.
B. Call the physician for an antianxiety medication: While the client may be experiencing anxiety or distress, immediately resorting to medication is not the most appropriate response to the client's existential question. Antianxiety medication may provide temporary relief of symptoms but does not address the underlying spiritual or existential distress. It is essential for the nurse to explore the client's concerns and provide holistic support rather than solely relying on pharmacological interventions.
C. Advise the client to pray for answers: This response imposes the nurse's religious or spiritual beliefs onto the client and may not be appropriate for individuals who do not share the same beliefs. It is essential for the nurse to respect the client's autonomy and beliefs while providing support and guidance. Instead of advising the client to pray, the nurse should focus on active listening, empathy, and providing nonjudgmental support.
D. Share personal religious beliefs with the client: Sharing personal religious beliefs with the client is not appropriate in this situation. Doing so may impose the nurse's beliefs onto the client, which can be perceived as intrusive or insensitive. It is essential for the nurse to maintain professional boundaries and respect the client's autonomy, beliefs, and preferences. The focus should be on providing empathetic support and addressing the client's emotional and existential concerns.
Correct Answer is C
Explanation
A. Hypovolemic shock: Hypovolemic shock is characterized by decreased blood volume, leading to inadequate tissue perfusion and oxygen delivery. The clinical findings described, such as sudden weight gain, bounding pulses, and elevated blood pressure, are not consistent with hypovolemic shock, which typically presents with hypotension, weak pulses, and signs of poor tissue perfusion.
B. Hemodilution: Hemodilution refers to a decrease in the concentration of blood components due to an increase in plasma volume. While weight gain may result from hemodilution, other clinical findings described, such as bounding pulses and elevated blood pressure, are not indicative of hemodilution.
C. Excess fluid volume: This is the correct answer. The sudden weight gain, bounding pulses, and elevated blood pressure suggest an excess of fluid volume. Bounding pulses can occur due to increased stroke volume from the heart pumping against increased volume, while elevated blood pressure can result from the increased fluid volume increasing cardiac output. Sudden weight gain is often attributed to fluid retention.
D. Deficient fluid volume: Deficient fluid volume, also known as dehydration, is characterized by insufficient fluid in the body. The clinical findings described, such as sudden weight gain and elevated blood pressure, are not consistent with deficient fluid volume. In dehydration, blood pressure tends to decrease rather than increase.
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