The nurse is documenting about an ulcer on the lateral aspect of the client's right great toe. The nurse notes that the ulcer is pale with well-defined edges and there is no evidence of bleeding
To help determine information about the origin of the client's ulcer, which of the following pieces of the assessment will be most useful for the nurse? 1. Skin turgor
2. Calf measurements
3. Homan's sign
4. Peripheral pulses
4
Rationale 1: The nurse can use information about the client's skin turgor to help assess the client's fluid balance.
Rationale 2: Calf measurements can be compared to determine if the client is developing edema. This information will be more helpful to use with a client who has venous insufficiency.
Rationale 3: Homan's sign can be used to help determine if the client has developed a deep vein thrombosis.
Rationale 4: Peripheral pulses should be assessed to determine if the client has arterial insufficiency. This is the most useful assessment at this time.
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When obtaining a urine specimen on an infant, the adhesive of the urine collector is placed between the _____________ and the _________________
ANS:
A hospice nurse is visiting a client who is being cared for by her daughter in her daughter's home. The client is no longer able to answer questions. The daughter is concerned that her mother may still be in pain
What assessment data may indicate that the client is in pain? A) Moaning while being turned B) Cool, dry skin C) Cheyne-Stokes respiratory pattern D) Cyanotic feet and lower legs
Consequences of nephrotic syndrome include
a. edema b. increased risk of CVD c. susceptibility to infection and rickets in children and PEM d. all of the above
On average, _____% of renal plasma flow (RPF) to the glomerulus is filtered into the Bowman's capsule
What will be an ideal response?