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

Answer and Explanation

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.

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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.

A. select organic canned vegetables." B. purchase lean deli meats for my sandwiches." C. purchase smoked meat products D. avoid processed foods."

Correct Answer is D

Explanation

D. Processed foods, including canned soups, snacks, and pre-packaged meals, are major sources of dietary sodium. By avoiding processed foods, the client can significantly reduce their sodium intake and better adhere to a low-sodium diet.

A. While organic vegetables may be a healthy choice for other reasons (such as reducing pesticide exposure), canned vegetables, whether organic or not, often contain added sodium for preservation. Therefore, selecting canned vegetables, even if organic, may not align with the goal of reducing sodium intake.

B. This statement suggests an understanding of choosing lower-sodium options for sandwiches. Lean deli meats, such as turkey or chicken breast, typically contain less sodium compared to processed or cured meats like salami or bologna. Opting for lean deli meats supports the client's effort to reduce sodium intake as part of a low-sodium diet.

C. This statement indicates a misunderstanding of a low-sodium diet. Smoked meats, such as smoked ham or bacon, are often high in sodium due to the curing and smoking process. Including smoked meat products in the diet would likely increase sodium intake, which contradicts the goal of reducing sodium.

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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)

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Naxlex Comprehensive Predictor Exams

Which of the following would be a barrier to active listening?

Correct Answer is B

Explanation

A nurse is providing teaching for a client who is placed on a low-sodium diet. Which statement made by the client demonstrates an understanding of dietary teaching? "I will:

Correct Answer is D

Explanation

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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)

Joint Commission (TJC) requires that a(n)