A student nurse documents the following: Lower left leg cool, mild edema, with dorsalis pedis, posterior knee and femoral pulse normal. How should this documentation be charted to communicate the assessment using appropriate medical terminology?
Left extremity cool to touch, normal pitting edema, with femoral, posterior tibial, and dorsalis pedis pulses palpable, +2.
Left lower extremity cool to touch, +2 pitting edema, with femoral, popliteal, and dorsalis pedis pulses palpable, +2.
Left lower leg cool to touch, +4 edema with femoral, posterial tibial, dorsalis and pedis pulses normal.
Left lower leg normal cool temperature, slight swelling, femoral, posterior tibial and dorsalis pedis pulses normal.
The Correct Answer is B
A) Left extremity cool to touch, normal pitting edema, with femoral, posterior tibial, and dorsalis pedis pulses palpable, +2: While this option describes the left extremity and includes some relevant details, it inaccurately uses "normal pitting edema" without specifying the degree of edema clearly. Additionally, it lists the posterior tibial pulse instead of the popliteal, which is more appropriate given the anatomical location.
B) Left lower extremity cool to touch, +2 pitting edema, with femoral, popliteal, and dorsalis pedis pulses palpable, +2: This documentation accurately describes the left lower extremity, specifies the degree of edema as "+2," and correctly identifies the relevant pulses as femoral, popliteal, and dorsalis pedis. This terminology is clear and concise, providing a comprehensive assessment of the vascular status.
C) Left lower leg cool to touch, +4 edema with femoral, posterial tibial, dorsalis and pedis pulses normal: This option incorrectly reports the degree of edema as "+4," which indicates severe swelling, not matching the original assessment of "mild edema." It also incorrectly lists the posterior tibial pulse, which should be popliteal.
D) Left lower leg normal cool temperature, slight swelling, femoral, posterior tibial and dorsalis pedis pulses normal: The term "normal cool temperature" is confusing and not standard terminology. Additionally, "slight swelling" lacks specificity regarding the degree of edema, which is important for a clinical assessment. Furthermore, it inaccurately refers to the posterior tibial pulse instead of the popliteal.
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View Related questions
Correct Answer is B
Explanation
A) Eupnea: Eupnea refers to a normal respiratory rate, typically between 12 to 20 breaths per minute for adults. Given that the client’s respiratory rate is significantly lower than this range, documenting the finding as eupnea would not accurately reflect the client’s condition.
B) Bradypnea: Bradypnea is defined as a slower-than-normal respiratory rate, usually less than 12 breaths per minute. With the client's rate at 9 breaths per minute, this is an example of bradypnea. It is crucial for the nurse to document this finding accurately, even though the client denies feeling short of breath, as it could indicate an underlying issue requiring further assessment.
C) Tachypnea: Tachypnea indicates a faster-than-normal respiratory rate, typically over 20 breaths per minute. Since the client's respiratory rate is low at 9 breaths per minute, labeling it as tachypnea would be incorrect and misleading.
D) Dyspnea: Dyspnea refers to difficulty or discomfort in breathing. Although the client does not report feeling short of breath, it is essential to note that the low respiratory rate could still lead to respiratory distress, but it does not meet the criteria for dyspnea based on the client's self-report. Therefore, documenting this finding as dyspnea would not be appropriate.
Correct Answer is A
Explanation
A) Crepitus: This is the correct term to document the grating sound heard when a joint is moved. Crepitus can indicate issues such as the presence of air in the joint, cartilage degeneration, or other pathologies. Using this specific term provides clarity to the medical record and helps other healthcare providers understand the nature of the joint's condition.
B) Positive joint sounds: This phrase is less specific and does not adequately describe the type of sound noted during the assessment. It may also lead to ambiguity, as it lacks the medical precision that crepitus provides.
C) Grating and popping: While this description conveys what the nurse observed, it is not a standardized medical term. Precise documentation is essential in medical records, and using non-standard language can lead to confusion.
D) Crackles: Typically associated with respiratory assessments, crackles refer to sounds heard in the lungs and are not applicable to joint examinations. Therefore, this term would be inappropriate for documenting findings related to joint movement.