What is the best way for the nurse to document the assessment of a client's foot on the Admission Database?

Multiple lesions on dorsal aspect of feet probably due to elder abuse

Four burned areas noted on plantar area of each foot

Several partially healed lesions on bottom of left foot, looks like cigarette burns

Four round, 2 cm in diameter lesions on plantar aspect of right foot

Answer and Explanation

The Correct Answer is D

A. Multiple lesions on the dorsal aspect of feet probably due to elder abuse: This option includes a speculative interpretation of the lesions and implies a potential cause (elder abuse) without clear evidence. Speculating about the cause of lesions without proper assessment or confirmation is inappropriate for documentation.

B. Four burned areas noted on the plantar area of each foot: This option describes the finding of burned areas on the plantar area of each foot, but it lacks specificity regarding the size or characteristics of the burns. Additionally, it does not differentiate between the left and right foot. Clarity and precision are important in documentation to ensure accurate communication of findings.

C. Several partially healed lesions on the bottom of the left foot, looks like cigarette burns: While this option provides some details about the location and appearance of the lesions, it lacks specificity regarding the number and size of the lesions. Additionally, it focuses only on the left foot, omitting any findings from the right foot.

D. Four round, 2 cm in diameter lesions on the plantar aspect of the right foot: This is the correct answer. It provides clear and specific details about the findings, including the number, size, and location of the lesions. Using objective descriptors such as "round" and "2 cm in diameter" enhances the clarity of the documentation. Additionally, specifying the location as "plantar aspect of the right foot" ensures accurate communication of the assessment findings.

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Free Nursing Study Resources

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

Explanation

When administering an enema to an adult patient with constipation, the nurse must insert the tubing into the patient's rectum to deliver the enema solution effectively. However, it's crucial to avoid inserting the tubing too far to prevent injury or discomfort to the patient. The recommended insertion distance varies depending on the individual patient's anatomy and the type of enema being administered.

A. 4 in. (10.2 cm):

Inserting the enema tubing approximately 4 inches (10.2 cm) into the patient's rectum is considered a safe and effective distance for most adult patients. This depth allows the enema solution to reach the sigmoid colon, facilitating the evacuation of stool and relieving constipation without risking insertion too deeply into the rectum.

B. 5 in (12.7 cm): Inserting the tubing 5 inches into the rectum is generally deeper than necessary and may increase the risk of injury or discomfort. This distance is not typically recommended for safe and effective administration of an enema.

C. 6 in. (15.25 cm): Inserting the tubing 6 inches into the rectum is deeper than necessary and may increase the risk of injury or discomfort. This distance is generally not recommended for safe and effective administration of an enema.

D. 2 in. (5.1 cm): Inserting the tubing 2 inches into the rectum is not considered a safe and effective distance for many adult patients. This distance does not allow for the effective delivery of the enema solution into the lower rectum and sigmoid colon without inserting the tubing too far.

E. 3 in. (7.6 cm): Inserting the tubing 3 inches into the rectum is also considered a safe and effective distance for many adult patients. This distance allows for the delivery of the enema solution into the lower rectum and sigmoid colon without inserting the tubing too far.

A. Provide information about sexual orientation and comment on alternatives. B. Communicate an open, accepting attitude. C. Provide a referral for the client to see a sex therapist. D. Teach the client about normal sexual health.

Correct Answer is B

Explanation

A. Provide information about sexual orientation and comment on alternatives: This step involves providing information about sexual orientation and discussing alternatives. However, it may not be the first step in the PLISSIT model. First, the nurse should establish a supportive and nonjudgmental environment, which is addressed in option B.

B. Communicate an open, accepting attitude: This is the correct response. In the PLISSIT model, the first step is to establish an open, accepting attitude. This involves creating a safe space for the client to express their concerns without fear of judgment or discrimination. By demonstrating acceptance and empathy, the nurse encourages the client to feel comfortable discussing sensitive topics related to sexual orientation.

C. Provide a referral for the client to see a sex therapist: Referral to a sex therapist may be appropriate for clients who require specialized intervention beyond the nurse's scope of practice. However, in the PLISSIT model, referral to a specialist typically occurs after the initial steps of establishing rapport and assessing the client's needs.

D. Teach the client about normal sexual health: While education about normal sexual health is an important aspect of sexual health nursing, it may not be the first step in the PLISSIT model. Initially, the focus is on creating a supportive environment and building trust with the client.

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What is the best way for the nurse to document the assessment of a client's foot on the Admission Database?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse must administer an enema to an adult patient with constipation. Which is a safe and effective distance for the nurse to insert the tubing into the patient's rectum? (SELECT ALL THAT APPLY)

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

Explanation

The nurse is caring for a client who expresses concerns about sexual orientation. When using the PLISSIT model, which step will the nurse take first?

Correct Answer is B

Explanation

The nurse is addressing a client's questions after admission to the hospital. What is an accurate description of a living will?

The nurse knows that the difference between "spirituality" and "religion" is that spirituality:

The nurse collects a urine sample from a newly admitted client. The color of the urine is slightly pink. The first nursing action would be to:

When learning of a new cancer diagnosis, the client states, "If it is God's will, I will survive this." The nurse who is providing spiritually competent care would respond by:

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When working with clients of any age, the nurse keeps in mind that the key to mutually-satisfying, healthy sexual relationships between partners is most often:

The nurse is completing an admission assessment. The client reports a 2-day history of hematuria. Which term describes this assessment finding?