The nurse explains isometric exercises to the patient on the rehabilitation unit.
Which explanation provided by the nurse is accurate?

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.

Choice A rationale:

The nurse mistakenly calling the patient's daughter "your wife" is a communication error but does not qualify as a sentinel event. Sentinel events are serious, largely preventable patient safety incidents that result in significant harm or death to the patient. Miscommunication, while important to address, does not fall under the category of a sentinel event.

Choice B rationale:

A surgical procedure performed on the wrong leg of a patient is a classic example of a sentinel event. Wrong-site surgery is a serious medical error that can lead to severe consequences for the patient. Proper protocols and procedures, such as time-outs and site marking, are in place to prevent such incidents, making this a sentinel event that requires immediate investigation and analysis to prevent recurrence.

Choice C rationale:

The surgical procedure being postponed by 30 minutes, while potentially inconvenient, does not constitute a sentinel event. Delays in surgical schedules are not uncommon due to various reasons such as emergencies or the complexity of preceding procedures. While delays should be minimized, they do not necessarily result in patient harm or death, making them different from sentinel events.

Choice D rationale:

The nurse failing to raise the bed to a working height during patient care is a safety concern but does not qualify as a sentinel event. It is important for nurses to adhere to proper body mechanics and safety protocols to prevent accidents and injuries. While this situation requires correction and education, it does not meet the criteria of a sentinel event.