The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer?

Compare the skin turgor of the client's upper and lower leg.

Observe the specific location and appearance of the ulceration.

Note any change in the color of the ulcer when the leg is moved.

Measure the degree of joint range of motion in the extremity.

Answer and Explanation

The Correct Answer is B

A. Skin turgor assesses skin elasticity and hydration, which is more indicative of general hydration status rather than specific types of insufficiency. While poor skin turgor might be observed in various conditions, it does not specifically differentiate between venous and arterial ulcers.
B. The location and appearance of the ulcer can provide significant clues about its etiology. Venous ulcers often appear on the lower legs, particularly around the medial malleolus (inside of the ankle), and tend to have irregular, shallow, and often wet or weepy edges.
C. Changes in color upon movement can provide insight into the type of insufficiency. For arterial ulcers, the leg may appear pale or blanched when elevated and may develop a reddish or purple color when lowered due to poor blood flow.
D. Measuring joint range of motion assesses flexibility and mobility rather than the type of ulcer. While joint mobility issues can be associated with various conditions, including those affecting the vascular system, it does not directly help in distinguishing between venous and arterial insufficiency ulcers.

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Correct Answer is A

Explanation

A. This response is a straightforward denial. It reflects a direct and possibly automatic answer that the client does not use recreational drugs. However, this type of response might be influenced by the phrasing of the question, which could lead the client to respond in a way that aligns with what they perceive as socially acceptable or expected.
B. This response indicates that the client acknowledges past use of a recreational drug (marijuana) but minimizes its frequency and significance. The response suggests that the phrasing of the question might have led the client to clarify their past behavior, showing an attempt to be honest while downplaying the extent of use.

C. This response suggests that the client is seeking clarification on what the term "recreational drugs" includes. The question might have been vague or broad, prompting the client to ask for a definition or to specify which substances are considered recreational drugs. This response indicates that the client might be unsure about whether their drug use falls into the category of recreational drugs.
D. This response implies that the client does use recreational drugs but does so infrequently or sporadically. It suggests a level of acknowledgment of occasional use without providing specifics. This type of answer might reflect that the client is uncomfortable with a direct yes/no response and opts for a more ambiguous acknowledgment.

Correct Answer is ["20"]

Explanation

The standard distance for a visual acuity test using the Snellen chart is 20 feet. This distance allows for an accurate assessment of how well a person can see the details of the letters on the chart, which is a common method used by eye doctors to measure visual acuity.

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The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While performing a health history the nurse asks the client, "You don't use recreational drugs, do you?" This approach is most likely to elicit which response from the client?

Correct Answer is A

Explanation

The nurse is assessing the visual acuity of a client who reports changes in vision. How many feet away from the Snellen chart should the client stand? (Enter a whole number only.)

Correct Answer is ["20"]

Explanation

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