While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?
Compare measured circumferences of each extremity joint.
Instruct the client to walk across the room and observe the gait.
Perform passive range of motion and compare the findings.
Measure the length of each leg and document the findings.
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Eats less salt-cured meats: Reducing the intake of salt-cured meats is generally a positive behaviour, especially for someone with hypertension. This behaviour aligns with dietary recommendations for managing high blood pressure.
B. Participates in healing rituals: Healing rituals are part of many cultural practices and can provide emotional and spiritual support. However, without further information, it's unclear if these rituals interfere with the prescribed treatment. This may warrant additional assessment to ensure they complement the medical regimen.
C. Uses herbal remedies: The use of herbal remedies could potentially interact with prescribed antihypertensive medications. This behaviour requires careful assessment to ensure there are no harmful interactions or adverse effects on the treatment plan.
D. Meditates in sweat lodges: Sweat lodges are a traditional practice for many Native Americans, providing physical and spiritual cleansing. However, the high temperatures and dehydration risks associated with sweat lodges could adversely affect blood pressure control and overall cardiovascular health. This behaviour requires further evaluation to ensure it is safe for the client with hypertension.
Correct Answer is B
Explanation
A. Auscultate the lymph node for the presence of a bruit.
Auscultating for a bruit over a lymph node may not be the most immediate or relevant action in this situation. While it could provide additional information about blood flow, it may not necessarily explain the cause of the enlarged lymph node.
B. Ask the client about any localized tenderness at the site.
This is an appropriate action. Localized tenderness at the site of an enlarged lymph node could indicate inflammation or infection. Gathering information about tenderness can help in understanding the possible cause of the lymphadenopathy.
C. Cover the inflamed area and notify the healthcare provider.
This is a reasonable action. Covering the inflamed area can help protect it from further irritation or infection. Notifying the healthcare provider is important because they can assess the lymph node, gather additional history, and determine if further evaluation or treatment is necessary.
D. Record this normal finding in the assessment record.
This option is incorrect. An enlarged, visible lymph node is not considered a normal finding. It could indicate underlying infection, inflammation, or another health issue. Recording it as a normal finding could lead to overlooking potential health concerns.
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