The nurse is caring for a client who was admitted to the medical unit. The healthcare provider states that the client's Romberg test is positive. In order to meet this client's elimination needs, which intervention will the nurse implement?
Obtain an order for a catheter
Allow the client to walk independently
Obtain a bedside commode
Limit fluid intake
The Correct Answer is C
A) Obtain an order for a catheter: While catheterization can help manage elimination needs, it is generally considered a more invasive approach and is not the first line of action unless absolutely necessary. The goal should be to maintain the client’s dignity and encourage as much independence as safely possible.
B) Allow the client to walk independently: Given that the Romberg test is positive, indicating potential balance issues, allowing the client to walk independently could increase the risk of falls and injury. Safety is a primary concern in this situation.
C) Obtain a bedside commode: This intervention is appropriate as it provides a safe and accessible option for the client to meet their elimination needs without the need to navigate to a bathroom, which may be challenging given their balance issues. A bedside commode allows for easier access while minimizing the risk of falls.
D) Limit fluid intake: Limiting fluid intake is not a safe or effective way to address elimination needs and could lead to dehydration and other complications. Encouraging appropriate fluid intake is important for overall health, provided the client can manage elimination safely.
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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.
Correct Answer is D
Explanation
A) Symmetry of lesions: While asymmetry can be a concern when assessing moles, it is not the most critical indicator when a lesion has already shown signs of burning and bleeding. Symmetry is one aspect of the overall assessment but does not immediately indicate danger in this scenario.
B) Border regularity: Irregular borders can suggest malignancy; however, the presence of burning and bleeding is a more pressing sign that warrants immediate attention. While border irregularity is important to assess, it is not as concerning as changes in color or the presence of symptoms like bleeding.
C) Diameter less than 6 mm: A diameter less than 6 mm is generally considered a normal size for moles and is not indicative of malignancy on its own. In this case, the burning and bleeding of the mole are more significant findings that raise concern, regardless of its size.
D) Color variation: Color variation in a pigmented lesion is a significant danger sign, as it can indicate changes that may suggest malignancy, especially when combined with other concerning symptoms like burning and bleeding. Variability in color may indicate the presence of different cell types and is a key factor in assessing the risk of melanoma.