While assessing a client, the nurse notices that the client's legs are asymmetrical. Which additional physical data should the nurse collect?
Compare measured circumferences of each extremity joint.
Instruct the client to walk across the room and observe the gait.
Perform passive range of motion and compare the findings.
Measure the length of each leg and document the findings.
The Correct Answer is D
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Open-ended question. This response is not an open-ended question. Open-ended questions typically invite the client to share more information or elaborate on their thoughts and feelings. Instead, the nurse's response acknowledges the client's feelings and demonstrates empathy without directly soliciting more information.
B. Clarification. This response is not clarification. Clarification involves seeking clarification or additional information to ensure understanding. The nurse's response does not seek clarification but rather acknowledges the client's emotions.
C. Empathizing. This response is empathizing. Empathizing involves recognizing and understanding the client's emotions and expressing empathy. The nurse's response acknowledges the client's difficult situation and validates their feelings of distress, demonstrating empathy and understanding.
D. Paraphrasing. This response is not paraphrasing. Paraphrasing involves restating the client's message in the nurse's own words to confirm understanding. The nurse's response does not restate the client's message but rather expresses empathy and validation of the client's emotions.
Correct Answer is C
Explanation
A. Compress the tissue around the ankles: Compressing the tissue around the ankles can assess for edema but does not provide direct information about arterial circulation.
B. Observe plantar flexion and dorsiflexion: Observing plantar flexion and dorsiflexion assesses motor function and muscle strength but does not directly assess arterial circulation.
C. Palpate the volume of the pedal pulses: Palpating pedal pulses is a direct method to assess arterial blood flow to the lower extremities. It provides information about the strength and quality of arterial circulation.
D. Stroke the soles and note toe movement: Stroking the soles and noting toe movement is the Babinski reflex test, which assesses neurological function, not arterial circulation.
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