Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)
irregular wound borders
distinct wound borders to plantar aspect of foot
Patient reports 9 (0-10) scale to area
minimal serous drainage
+3 edema to the mid-calf
Correct Answer : A,E
A. Venous ulcers often have irregular wound borders. This is due to the underlying venous hypertension and tissue breakdown, which can lead to irregular shapes of the ulcer.
E. Significant edema, particularly in the lower leg and ankle area (often graded as +2 or +3), is commonly associated with venous ulcers. Venous insufficiency leads to fluid accumulation in the tissues, resulting in edema.
B. This is less likely to be associated with a venous ulcer. Venous ulcers typically occur on the lower leg, particularly around the medial or lateral malleolus, rather than on the plantar aspect of the foot.
C. Severe pain, especially on a scale of 9 out of 10, is less typical of venous ulcers. Venous ulcers are usually associated with mild to moderate discomfort or pain, often described as aching or heaviness rather than severe pain.
D. Venous ulcers typically exhibit moderate to heavy serous drainage. This is due to the chronic inflammation and venous congestion that characterize venous insufficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","C","D"]
Explanation
A. Older adult skin is typically more fragile and prone to injury and tears due to decreased elasticity and thinning. Handling the skin gently helps prevent trauma, skin tears, and bruising, promoting skin integrity and comfort.
C. Older adults are more susceptible to temperature changes and may have difficulty regulating body temperature. Appropriate clothing that helps maintain warmth without causing overheating is essential. This includes wearing layers that can be easily adjusted and using fabrics that are breathable and comfortable.
D. Older adult skin tends to be drier due to decreased oil production and reduced hydration levels. Applying moisturizers after bathing helps replenish lost moisture, maintain skin hydration, and prevent dryness and cracking. It is important to choose moisturizers that are suitable for older adult skin and free from irritants.
B. Daily bathing may not be necessary or suitable for all older adults. Excessive bathing can strip the skin of natural oils, leading to dryness and irritation. Instead, the nurse should promote bathing frequency based on individual skin needs, such as using mild, moisturizing cleansers and lukewarm water.
E. Adequate hydration is crucial for maintaining skin health and overall well-being in older adults. While fluid needs vary among individuals, restricting fluid intake to such a low level (1000 mL) is generally not
appropriate unless medically indicated. Older adults should be encouraged to maintain adequate hydration to support skin elasticity, circulation, and overall health.
Correct Answer is ["B","C","D","F"]
Explanation
B. Physician and nurse practitioner orders specify the medical treatments, medications, and interventions prescribed for the client. These orders are essential for guiding care at the subacute care facility and are a critical part of the legal health record.
C. A living will, also known as an advance directive, outlines the client's preferences for medical treatment and care in the event they are unable to communicate their wishes. It is a legal document that guides decision-making regarding end-of-life care.
D. Vital sign flow records document the client's vital signs over time, including measurements such as blood pressure, heart rate, respiratory rate, and temperature. These records are essential for monitoring the client's health status and detecting trends or changes.
F. Nurses' assessments document the nursing observations, assessments, and interventions provided to the client. These assessments are crucial for ongoing nursing care and should be included in the legal health record.
A. Event or unusual occurrence reports document any incidents or deviations from the standard of care that occur during the client's hospitalization. These reports are important for quality improvement and risk management but are typically not included in the legal health record unless they directly impact the client's care.
E. Proof of residence or property ownership documents are not typically included in the legal health record. These documents are unrelated to the client's medical care and are considered personal or administrative records.
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