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

Answer and Explanation

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.

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

Explanation

A. Clients with dementia often experience cognitive decline, which can affect their ability to navigate their surroundings safely. Modifying the environment can include simplifying the layout, reducing clutter, using clear signage, and ensuring adequate lighting to enhance orientation and reduce confusion.

B. Communication difficulties are common in dementia. Using short, simple sentences helps clients better understand instructions and information. It reduces confusion and frustration, promoting effective communication and cooperation during care.

C. Maintaining independence and dignity is crucial for clients with dementia. Allowing them to participate in Activities of Daily Living (ADLs) to the extent possible helps preserve their functional abilities, boosts their self-esteem, and promotes a sense of control over their environment.

E. Providing choices within a structured framework can empower clients with dementia. It allows them to maintain some control over their daily routine and decisions, thereby enhancing their sense of autonomy and reducing agitation or resistance to care.

D. This is not an appropriate intervention. Social interaction, including visits from family members, can have significant emotional and psychological benefits for clients with dementia. It can help reduce feelings of isolation, improve mood, and provide reassurance and familiarity.

A. stop aggressive treatment for my cancer B. call 911 if my symptoms worsen C. make an appointment for home physical therapy D. have a prolonged life expectancy

Correct Answer is A

Explanation

A. This statement indicates an understanding of hospice care because hospice typically involves discontinuing aggressive treatments such as chemotherapy, radiation, or surgeries that are aimed at curing the cancer. Instead, the focus shifts to palliative care to manage symptoms and improve quality of life.

B. This statement suggests the client may not fully understand hospice care. In hospice, the emphasis is on managing symptoms in the home setting with the support of hospice nurses and caregivers. Calling 911 for symptom management contradicts the philosophy of hospice, which is to avoid aggressive interventions and hospitalizations.

C. This statement indicates a misunderstanding of hospice care. Hospice care focuses on comfort and quality of life rather than rehabilitative services such as physical therapy. In hospice, the care provided is primarily palliative and supportive rather than rehabilitative.

D This statement would indicate a misunderstanding of hospice care. In hospice, the prognosis is typically a life expectancy of six months or less if the disease follows its natural course. Hospice care is provided when curative treatments are no longer effective or desired, and the focus is on comfort rather than prolonging life.

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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)

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is A

Explanation

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