The nurse has performed a thorough nursing assessment of the care of a patient with chronic leg ulcers. The nurse's assessment should include which of the following components? Select all that apply
A) Location and type of pain
B) Apical heart rate
C) Bilateral comparison of peripheral pulses
D) Comparison of temperature in the patient's legs
E) Identification of mobility limitations
Ans: A, C, D, E
Feedback:
A careful nursing history and assessment are important. The extent and type of pain are carefully assessed, as are the appearance and temperature of the skin of both legs. The quality of all peripheral pulses is assessed, and the pulses in both legs are compared. Any limitation of mobility and activity that results from vascular insufficiency is identified. Not likely is there any direct indication for assessment of apical heart rate, although peripheral pulses must be assessed.
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