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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.

Answer and Explanation

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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A. Re-assess in 15 minutes B. Ask the patient to open eyes on command C. Document the findings D. Notify the physician

Correct Answer is C

Explanation

A) Re-assess in 15 minutes: While regular assessments are important in a neurological evaluation, if the Glasgow Coma Scale (GCS) score is 15, indicating the patient is fully alert and oriented, there may not be an immediate need to re-assess so soon unless the patient's condition changes.

B) Ask the patient to open eyes on command: If the GCS score is already determined to be 15, this indicates that the patient is responsive and capable of opening their eyes spontaneously. Asking the patient to open their eyes is unnecessary in this context since the score already reflects full responsiveness.

C) Document the findings: Documenting the GCS score of 15 is crucial as it establishes a baseline for the patient’s neurological status. This documentation is essential for ongoing assessments and monitoring, providing a record of the patient’s condition at this moment.

D) Notify the physician: Notifying the physician is not required for a GCS score of 15, as this score indicates a normal level of consciousness. Communication with the physician would be warranted only if there were changes in the patient's condition or a lower GCS score observed.

A. The patient's integumentary system is within normal limits for his age B. The patient may have a metabolic condition causing him to feel cold C. The patient has abnormal thinning of skin D. The patient should have elastic turgor

Correct Answer is B

Explanation

A) The patient's integumentary system is within normal limits for his age: While thinning skin and decreased turgor can be common in older adults, the specific combination of findings, including the patient feeling cold, suggests that further investigation is warranted rather than assuming they are normal.

B) The patient may have a metabolic condition causing him to feel cold: Thin skin and non-elastic turgor can be indicative of aging, but the sensation of always feeling cold may point to an underlying metabolic condition, such as hypothyroidism or poor circulation, which can affect thermoregulation.

C) The patient has abnormal thinning of skin: While skin thinning is common in older adults, it is not necessarily "abnormal" in the context of aging. However, in conjunction with other symptoms like non-elastic turgor and cold sensitivity, it may warrant further evaluation.

D) The patient should have elastic turgor: In older adults, it is common to see decreased elasticity and turgor of the skin. Therefore, expecting the patient to have elastic turgor may not be appropriate, as it reflects the natural aging process rather than a healthy standard.

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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?

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Correct Answer is C

Explanation

Correct Answer is B

Explanation

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Take full exam for free 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?

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Correct Answer is C

Explanation

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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?