Which of the following assessment findings would lead the nurse to suspect the client has a venous ulcer to the right lower extremity? (SELECT ALL THAT APPLY)
irregular wound borders
distinct wound borders to plantar aspect of foot
Patient reports 9 (0-10) scale to area
minimal serous drainage
+3 edema to the mid-calf
Correct Answer : A,E
A. Venous ulcers often have irregular wound borders. This is due to the underlying venous hypertension and tissue breakdown, which can lead to irregular shapes of the ulcer.

E. Significant edema, particularly in the lower leg and ankle area (often graded as +2 or +3), is commonly associated with venous ulcers. Venous insufficiency leads to fluid accumulation in the tissues, resulting in edema.
B. This is less likely to be associated with a venous ulcer. Venous ulcers typically occur on the lower leg, particularly around the medial or lateral malleolus, rather than on the plantar aspect of the foot.
C. Severe pain, especially on a scale of 9 out of 10, is less typical of venous ulcers. Venous ulcers are usually associated with mild to moderate discomfort or pain, often described as aching or heaviness rather than severe pain.
D. Venous ulcers typically exhibit moderate to heavy serous drainage. This is due to the chronic inflammation and venous congestion that characterize venous insufficiency.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
B Leaning away from the client can convey disinterest, distraction, or a lack of engagement. It creates physical distance and may inhibit the client from feeling heard or valued. Thus, leaning away from the client can be a barrier to active listening as it diminishes the nurse's ability to fully attend to and understand the client's message.
A. An open posture, where the nurse's body is facing the client with arms uncrossed and relaxed, signals openness and receptivity. It encourages communication and shows the client that the nurse is engaged and attentive. Therefore, an open posture promotes active listening rather than serving as a barrier.
C. Eye contact is essential for effective communication and active listening. It demonstrates attentiveness, interest, and respect. Establishing eye contact helps the nurse to connect with the client and encourages them to continue sharing their thoughts and feelings. Therefore, eye contact supports active listening rather than hindering it.
D. Sitting squarely facing the client promotes engagement and shows that the nurse is focused on the client. It facilitates direct communication and helps the nurse to observe the client's nonverbal cues effectively. This posture encourages open dialogue and supports active listening rather than acting as a barrier.
Correct Answer is D
Explanation
D. When clients perceive that the knowledge or information being presented is beneficial to their health outcomes, they are more likely to be motivated to learn. Understanding how the knowledge can improve their health, manage their condition, or prevent complications provides intrinsic motivation to engage in learning activities.
A. While health literacy is important for understanding health information, having a high level of health literacy alone does not guarantee motivation to learn. Motivation to learn is more about personal engagement and perceived relevance of the information to one's own health and well-being.
B. While this may provide motivation for compliance with treatment plans or learning specific self-care tasks required for discharge, it does not necessarily translate to a strong motivation to learn beyond immediate needs related to discharge.
C. Formal education may contribute to overall cognitive abilities and learning skills, but it does not automatically translate into motivation to learn in a healthcare context. Motivation to learn is more about personal interest, perceived relevance, and understanding the benefits of acquiring new knowledge.
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