When completing the assessment of an immobilized patient, the ...

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When completing the assessment of an immobilized patient, the most likely place for the nurse to assess edema includes which of the following? (Select all that apply.)
 
  a. Face
  b. Feet
  c. Sacrum
  d. Abdomen
  e. Legs

Question 2

A patient is admitted from the emergency department. The nurse notices that the patient and family are anxious. During the admission process the nurse should do which of the following? (Select all that apply.)
 
  a. Continue with the examination even if the patient is anxious to get it done.
  b. Disregard cultural differences to gather therapeutic data.
  c. Provide a thorough explanation of the purpose of each assessment.
  d. Provide a thorough explanation of the steps of each assessment.
  e. Maintain a formal professional approach.

[Pamela.irrgang@yahoo.com]

Answer to Question 1

B, C, E
Because edema moves to dependent body regions as a result of gravity, assessment of the immobilized patient includes the sacrum, legs, and feet. Face and abdomen are not dependent areas.

Answer to Question 2

C, D
Many patients find an examination tiring or stressful, or they experience anxiety about possible findings. A thorough, simple, and clear explanation of the purpose and steps of each assessment lets patients know what to expect and helps them cooperate with each step. As you examine each body system, give a detailed explanation. Convey an open, professional, and relaxed approach. A stiff, formal approach will inhibit the patient's ability to communicate, but being too casual will not give the patient confidence in your ability. It is sometimes necessary to stop the examination and ask how the patient feels. Do not force a patient to continue. Findings will be more accurate if you postpone for when the patient can cooperate and relax. Remember that cultural differences influence a patient's behavior. Consider the patient's health beliefs, use of alternative therapies, nutritional habits, relationships with family, and comfort with your physical closeness during the examination and history taking. If necessary, obtain a medical translator who can correctly interpret to a patient who does not speak English.

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Excellent

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Gracias!