Patient Data

Exhibits

During the assessment, the nurse notes that the areas are filled with a fluid-like substance.

Which of the following primary skin lesions contain fluid? Select all that apply.

Choice A Reason:
Performing passive range of motion and compare the findings is inappropriate. While assessing passive range of motion can provide information about joint mobility and flexibility, it may not directly address the asymmetry observed in the legs. Range of motion assessment is more relevant for evaluating joint function and flexibility rather than leg length asymmetry.
Choice B Reason:
Comparing measured circumferences of each extremity joint is inappropriate. Measuring circumferences of extremity joints may help identify differences in muscle mass or swelling, but it may not directly address the asymmetrical leg length observed. Circumference measurements are more relevant for assessing muscle bulk or detecting signs of edema rather than leg length asymmetry.
Choice C Reason:
Instructing client to walk across the room and observe the gait is inappropriate. Observing the client's gait can provide valuable information about their walking pattern and any abnormalities in movement. While an abnormal gait may be associated with leg length asymmetry, directly measuring leg length would provide more precise data for evaluation.
Choice D Reason:
Measuring the length of each leg and document the findings is appropriate. Measuring the length of each leg can help identify any significant differences in leg length, which could be contributing to the asymmetry observed. Leg length discrepancy can result from various musculoskeletal conditions such as scoliosis, hip dysplasia, or unequal growth rates. Documenting the findings allows for accurate tracking of changes over time and provides important information for healthcare providers to determine appropriate interventions, such as orthotic devices or physical therapy.

Choice A Reason:
Audible thud without pain is incorrect. An audible thud without pain would not be an expected response when percussing the costovertebral angle (CVA) in a client with pyelonephritis. Pyelonephritis typically presents with tenderness upon percussion of the CVA due to inflammation or infection of the kidneys. The absence of pain in this scenario would not be consistent with the expected response.
Choice B Reason:
Rigidity and firmness are incorrect. Rigidity and firmness upon percussion of the costovertebral angle (CVA) may suggest muscle tension or guarding, rather than the tenderness typically associated with kidney inflammation or infection such as pyelonephritis. While guarding can occur in response to pain, it is not the expected response when assessing for kidney tenderness.
Choice C Reason:
Rebound tenderness is incorrect. Rebound tenderness refers to the exacerbation of pain upon release of pressure, typically observed in conditions such as peritonitis. While rebound tenderness may be present in some abdominal conditions, it is not the expected response when percussing the costovertebral angle (CVA) to assess for kidney tenderness in pyelonephritis. In pyelonephritis, tenderness upon initial percussion is more indicative of the condition.
Choice D Reason:
Sharp, severe pain is correct. Sharp, severe pain upon percussing the CVA suggests tenderness, which can be indicative of kidney inflammation or infection, such as pyelonephritis. This finding would support the diagnosis and help guide further assessment and treatment.