Author Question: The nurse documents edema in the ankles as 3+ for a client. What does this documentation indicate? ... (Read 64 times)

kamilo84 · **on:** Jun 25, 2018

The nurse documents edema in the ankles as 3+ for a client. What does this documentation indicate?

1. There is slight depression of the skin.
2. The leg is visibly swollen with deep pitting.
3. The leg is very swollen with very deep pitting.
4. The leg is not changed in size, with mild-to-moderate pitting.

Question 2

The nurse is obtaining the services of a translator to assist with the assessment of a non-English speaking client. What should the nurse take into consideration when using a translator? (Select all that apply.)

1. Look at the client when talking.
2. Use a family member to reduce the cost.
3. Ask questions in groups to reduce repetition.
4. Have the translator ask the client questions from a printed paper.
5. Arrange the room so the client can see the nurse and translator.

nathang24 · **Reply #1 on:** Jun 25, 2018

Answer to Question 1

Answer: 2

1. Slight depression is documented as 1+ edema.
2. Visible swelling with deep pitting is 3+ pitting edema.
3. A very swollen leg with very deep pitting is documented as 4+.
4. Mild-to-moderate pitting is described as 2+ edema.

Answer to Question 2

Answer: 1, 5

1. When using a translator the nurse should look at the client when talking.
2. It is best to use a facility translator as using the family to translate can lead to miscommunicated information as well as the patient being uncomfortable sharing information with family members.
3. The nurse should state questions one at a time.
4. The nurse should ask the questions one at a time in clear concise terms.
5. When using a translator the room should be arranged so the client can see both the nurse and the translator at the same time.