The nurse asks the patient to dorsiflex and plantarflex both feet against the nurse's hands.
What is the nurse assessing in whole, or part, with this action? Select all that apply.

The strength of the lower extremities.

The patient's sense of balance.

The presence of edema.

The range of motion of the ankle.

The status of the patient's skin turgor.

Answer and Explanation

Correct Answer : A,B,D

Choice A rationale:

Assessing the strength of the lower extremities is one of the objectives of asking the patient to dorsiflex and plantarflex both feet against the nurse's hands. This action helps evaluate the muscle strength of the lower limbs, providing information about the patient's neuromuscular function.

Choice B rationale:

Assessing the patient's sense of balance is another objective of this action. Dorsiflexion and plantarflexion require coordination and balance. If the patient struggles to maintain balance while performing these movements, it could indicate issues with proprioception or neurological deficits.

Choice C rationale:

Assessing the presence of edema is not directly related to dorsiflexion and plantarflexion movements. Edema assessment typically involves inspecting and palpating specific areas of the body, such as the ankles, to check for swelling, discoloration, and pitting.

Choice D rationale:

Evaluating the range of motion of the ankle joint is a key aspect of asking the patient to dorsiflex and plantarflex both feet against the nurse's hands. This action allows the nurse to observe how far the patient can move their ankles, providing valuable information about joint flexibility and function.

Choice E rationale:

Assessing the status of the patient's skin turgor involves checking the skin's elasticity and hydration level, usually by pinching and observing how quickly the skin returns to its normal position. This assessment is unrelated to the dorsiflexion and plantarflexion movements and is not applicable in this context.

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Correct Answer is ["B","E"]

Explanation

Choice A rationale:

Using correction fluid to correct an erroneous written entry is not appropriate as it can obscure the information and raise questions about the accuracy of the documentation. It is better to strike through the error with a single line, write the correct information, and sign and date the correction.

Choice B rationale:

Documenting changes in the patient's status is crucial for ensuring continuity of care and keeping all healthcare providers informed about the patient's condition.

Choice C rationale:

Leaving a blank line for the charge nurse to add additional documentation is not recommended. Each entry should be complete and include all relevant information at the time of documentation.

Choice D rationale:

Planning to finish charting the procedure after returning from a break is not appropriate. Charting should be done in real-time to ensure accuracy and timeliness of the information.

Choice E rationale:

Charting using military (24-hour) time is appropriate as it reduces confusion and ensures a standardized way of documenting time across different healthcare settings.

A. Hemoglobin. B. Hematocrit. C. Platelet count. D. Prothrombin time (PT). E. International normalized ratio (INR). .

Correct Answer is D

No explanation

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The nurse asks the patient to dorsiflex and plantarflex both feet against the nurse's hands.What is the nurse assessing in whole, or part, with this action? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is ["B","E"]

Explanation

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The nurse asks the patient to dorsiflex and plantarflex both feet against the nurse's hands.
What is the nurse assessing in whole, or part, with this action? Select all that apply.