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 D
Explanation
D. Rectal temperature measurement involves inserting a thermometer into the rectum. This method provides the most accurate reflection of core body temperature because the rectum closely mirrors internal body temperature. It is often used in infants, young children, and patients who are unable to have their temperature taken orally.
A. Axillary temperature measurement involves placing the thermometer in the armpit. This method is convenient and non-invasive but tends to provide the lowest temperature readings compared to other sites. It is suitable for screening purposes but may not be as accurate as other methods.
B. Skin temperature can vary widely based on environmental factors, circulation, and local skin conditions. Surface skin temperature may not accurately reflect core body temperature and is not typically used for precise temperature measurement in clinical settings.
C. Oral temperature measurement involves placing the thermometer under the tongue. This method is commonly used and provides a reasonably accurate reflection of core body temperature. It is convenient and generally well-tolerated by clients who are conscious and able to cooperate.
Correct Answer is A
Explanation
A. Vitamin D is often referred to as the "sunshine vitamin" because the body produces it in response to sunlight exposure on the skin. Spending more time indoors reduces sunlight exposure, which can lead to insufficient production of vitamin D in the body. Vitamin D is important for bone health, immune function, and other physiological processes.
B. Vitamin E deficiency is rare in healthy individuals with a balanced diet. It is primarily found in foods such as nuts, seeds, and vegetable oils. Deficiency can occur in conditions where fat absorption is impaired or in certain genetic disorders.
C. There are several B vitamins (e.g., B1, B2, B6, B12) that are essential for various metabolic processes in the body. Deficiencies in specific B vitamins can occur due to inadequate dietary intake, malabsorption
disorders, or other medical conditions. However, preference for indoor activities does not directly correlate with increased risk of vitamin B deficiency.
D. Vitamin A deficiency is more commonly associated with inadequate intake of foods rich in vitamin A (e.g., liver, carrots, sweet potatoes) rather than sunlight exposure. Vitamin A is important for vision, immune function, and cellular growth.
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