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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is C

Explanation

A. Cultural assessment: A cultural assessment involves gathering information about the client's cultural background, beliefs, practices, and preferences to provide culturally sensitive care. While the decision to donate organs may be influenced by cultural factors, assisting the client with alternatives, examining pros and cons, and eliciting feelings about the decision are not specifically related to conducting a cultural assessment.

B. Selecting treatment: Assisting the client with selecting treatment involves discussing various treatment options and helping the client make informed decisions about their healthcare. While organ donation may be considered a treatment option in some contexts, the scenario described focuses more on helping the client clarify their values and make a decision about organ donation rather than selecting treatment for a specific health condition.

C. Values clarification: This is the correct option. Values clarification involves helping individuals explore and understand their personal values, beliefs, and preferences to make decisions that align with their values. In this scenario, the nurse is assisting the client with exploring the decision to donate organs by facilitating a process of examining alternatives, considering the pros and cons, and eliciting the client's feelings about organ donation. This approach helps the client clarify their values related to organ donation and make an informed decision based on their personal beliefs and preferences.

D. Defining religious beliefs: While religious beliefs may influence an individual's decision about organ donation, the nurse's role in this scenario is broader and focuses on helping the client clarify their values and make a decision about organ donation based on their personal beliefs and preferences. The nurse may address religious beliefs as part of the values clarification process but is primarily assisting the client in exploring their overall values and feelings about organ donation.

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.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

The client is struggling with the decision to donate organs after death. The nurse assists the client to list alternatives, examine the "pros" and "cons" and elicits the client's feelings about the decision. The nurse is assisting this client with:

Correct Answer is C

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

The nurse is caring for a client who is one day post op after having abdominal surgery. While auscultating bowel sounds for a full one minute, the nurse hears 3 bowel sounds. The nurse would chart this as bowel sounds.

The client reports to the nurse that their bowel movements are hard & difficult to pass. Which of the medications taken by the client most likely contributed to this problem? A/An:

A nurse is providing teaching to a client who takes opioid pain medication and has a new prescription for docusate sodium. Which of the following statements by the client indicates an understanding of the teaching?

The nurse is caring for a client who expresses concerns about sexual orientation. When using the PLISSIT model, which step will the nurse take first?

The nurse is concerned about a client's ability to withstand exposure to pathogens. What blood component should the nurse monitor?

A client is prescribed isotonic IV hydration for their current fluid balance problem. Which property of isotonic fluid replacement is essential for the nurse to understand?

The nurse is talking with a 14-year-old female client who has just had her first sexual experience with a boy. At this time, the nurse should assess the client's knowledge of: (SELECT ALL THAT APPLY)