During the health history, the client reported that her feet and ankles swell
occasionally. To assess for edema, what action the nurse take first?
A. Ask the client to lie down and elevate her feet and legs.
B. Observe and compare the client's lower extremities.
C. Gently compress the tissue on the top of the client's feet.
D. Ask the client to gently dorsiflex each of her feet.
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B
The RN should first assess for edema by observing a client's legs for any
obvious swelling and by comparing the two extremities for differences in
size.
Which nursing diagnoses are a priority when developing the client's plan of care?
(Select all that apply. One, some, or all options may be correct.)
,A. Impaired physical mobility
B. Disturbed body image
C. Risk for infection
D. Risk for impaired skin integrity.
E. Chronic lymphedema relate to status post breast cancer surgery.
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A, B, C, D
(A) Lymphedema can make mobility difficult, especially lower extremity
lymphedema. It is important to assess the client and refer to physical
therapy for exercises and activity restrictions.
(B) A client with lymphedema may have a disturbed body image from such
things as wearing over-sized clothes or two different sized shoes. It is
important to address these things with the client.
(C) Infection may be common in lymphedema; pooling of protein-rich
lymph fluid increases cellulitis.
(D) Skin on the affected arm may be more dry than normal. Good skin care
is essential to prevent infection; wraps and compression stockings may
retain moisture against the skin.
The nurse prepares to complete a history and physical assessment.
The nurse reviews the client's initial complaint that her feet feel numb. Which
assessment should the nurse perform first?
A. Locate the inguinal lymph nodes.
B. Measure toenail capillary refill.
C. Compare calf circumferences.
D. Palpate the dorsalis pedis pulses.
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, D
Because the client has complained of numbness, it is important to assess
for the presence and strength of the pedal pulses, a measure of the arterial
circulation to the feet. The acute absence of arterial circulation would
require immediate intervention.
The nurse determines that the client's wound is a stage II pressure ulcer.
The nurse notes that the wound is round and 0.5 cm in diameter. To assess for the
presence of any undermining tracts, what action should the nurse implement?
A. Note the amount and appearance of any drainage to help determine the depth.
B. Gently irrigate the wound with sterile saline to help determine the depth.
C. Insert a sterile, cotton-tipped applicator to measure the depth.
D. Use sterile forceps to apply sterile packing to help determine the depth.
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C
A sterile, cotton-tipped applicator can be gently inserted to measure the
depth of the wound and any undermining tracts.
How should Cilostazole be taken?
A. With 2 full glass of water or juice.
B. One hour before, or two hours after a meal.
C. Prior to driving.
D. In the morning and before bed.
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occasionally. To assess for edema, what action the nurse take first?
A. Ask the client to lie down and elevate her feet and legs.
B. Observe and compare the client's lower extremities.
C. Gently compress the tissue on the top of the client's feet.
D. Ask the client to gently dorsiflex each of her feet.
Give this one a try later!
B
The RN should first assess for edema by observing a client's legs for any
obvious swelling and by comparing the two extremities for differences in
size.
Which nursing diagnoses are a priority when developing the client's plan of care?
(Select all that apply. One, some, or all options may be correct.)
,A. Impaired physical mobility
B. Disturbed body image
C. Risk for infection
D. Risk for impaired skin integrity.
E. Chronic lymphedema relate to status post breast cancer surgery.
Give this one a try later!
A, B, C, D
(A) Lymphedema can make mobility difficult, especially lower extremity
lymphedema. It is important to assess the client and refer to physical
therapy for exercises and activity restrictions.
(B) A client with lymphedema may have a disturbed body image from such
things as wearing over-sized clothes or two different sized shoes. It is
important to address these things with the client.
(C) Infection may be common in lymphedema; pooling of protein-rich
lymph fluid increases cellulitis.
(D) Skin on the affected arm may be more dry than normal. Good skin care
is essential to prevent infection; wraps and compression stockings may
retain moisture against the skin.
The nurse prepares to complete a history and physical assessment.
The nurse reviews the client's initial complaint that her feet feel numb. Which
assessment should the nurse perform first?
A. Locate the inguinal lymph nodes.
B. Measure toenail capillary refill.
C. Compare calf circumferences.
D. Palpate the dorsalis pedis pulses.
Give this one a try later!
, D
Because the client has complained of numbness, it is important to assess
for the presence and strength of the pedal pulses, a measure of the arterial
circulation to the feet. The acute absence of arterial circulation would
require immediate intervention.
The nurse determines that the client's wound is a stage II pressure ulcer.
The nurse notes that the wound is round and 0.5 cm in diameter. To assess for the
presence of any undermining tracts, what action should the nurse implement?
A. Note the amount and appearance of any drainage to help determine the depth.
B. Gently irrigate the wound with sterile saline to help determine the depth.
C. Insert a sterile, cotton-tipped applicator to measure the depth.
D. Use sterile forceps to apply sterile packing to help determine the depth.
Give this one a try later!
C
A sterile, cotton-tipped applicator can be gently inserted to measure the
depth of the wound and any undermining tracts.
How should Cilostazole be taken?
A. With 2 full glass of water or juice.
B. One hour before, or two hours after a meal.
C. Prior to driving.
D. In the morning and before bed.
Give this one a try later!
