A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?

Choice A reason:

Monitoring the client’s calf for edema is important in assessing for complications such as deep vein thrombosis (DVT) or compartment syndrome, but it is not the primary technique for assessing neurovascular status. Edema can indicate fluid accumulation and potential vascular issues, but it does not directly assess the nerve function or blood flow to the extremity.

Choice B reason:

Palpating the femoral pulse is crucial in assessing the neurovascular status of a client with a femur fracture. The femoral pulse provides information about the blood flow to the lower extremity. A strong, palpable pulse indicates good arterial blood flow, while a weak or absent pulse may suggest vascular compromise, which requires immediate attention. This assessment helps ensure that the blood supply to the limb is adequate, which is vital for healing and preventing complications.

Choice C reason:

Measuring the circumference of the thigh can help monitor for swelling and changes in muscle mass, but it is not a direct assessment of neurovascular status. While it can provide useful information about the extent of swelling or atrophy, it does not evaluate the nerve function or blood flow directly.

Choice D reason:

Instructing the client to wiggle his toes is a useful technique to assess motor function and nerve integrity. However, it is not sufficient on its own to assess the entire neurovascular status. It should be part of a comprehensive assessment that includes checking pulses, sensation, and capillary refill.

Choice A reason: Providing the client with articles from the internet that explain colon cancer stages is not the best approach. While it is important for the client to understand their condition, the nurse should ensure that the information is accurate and tailored to the client’s specific situation. Additionally, the nurse should facilitate a direct conversation between the client and the healthcare provider to address any questions or concerns.

Choice B reason: Encouraging the client to write down questions to ask the provider is an excellent approach. This empowers the client to actively participate in their care and ensures that they have a clear understanding of their diagnosis and treatment options. It also helps the client to remember important questions during their consultation with the provider.

Choice C reason: Explaining the various options available for treatment based on the cancer stage is not within the nurse’s scope of practice. Detailed discussions about treatment options should be conducted by the healthcare provider, who has the expertise to provide accurate and comprehensive information tailored to the client’s specific medical condition.

Choice D reason: Assuring the client that the provider will explain what has been planned is a supportive response, but it does not actively engage the client in their care. While it is important to reassure the client, the nurse should also encourage the client to prepare questions and participate in discussions with the provider to ensure they fully understand their treatment plan.