A client is admitted with a venous insufficiency of the right leg. What assessment findings does the nurse expect to find with this condition?

Poor hair growth

Weak pulse

Edema

Calf muscle atrophy (shrinkage)

Pale color

Answer and Explanation

The Correct Answer is C

A. Poor hair growth is more associated with arterial insufficiency.
B. A weak pulse may suggest arterial, not venous, insufficiency.
C. Edema is a common finding in venous insufficiency due to fluid pooling in the extremities.
D. Muscle atrophy is not typically associated with venous insufficiency.
E. Pale color is more indicative of arterial insufficiency, while venous insufficiency may present with darkened or reddish skin.

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Correct Answer is A

Explanation

A. A heave (or lift) often indicates ventricular hypertrophy or enlargement, suggesting increased workload on the heart.
B. Turbulent blood flow may lead to murmurs but is not specifically associated with a heave.
C. A persistently slow heartbeat is referred to as bradycardia and does not correlate with a heave.
D. An extreme pulse deficit relates to discrepancies between heartbeats and palpable pulses but is not linked to a heave.
E. Coronary artery blockage would not directly produce a heave; it typically leads to ischemic changes.

A. Decreased lung sounds on expiration B. Respirations are 40 breaths/minute C. Anterior-posterior diameter ratio is 1:1 D. Hyperresonance is noted to percussion E. Decreased tactile fremitus is present

Correct Answer is B

Explanation

A. Decreased lung sounds on expiration are common in COPD patients due to airway obstruction but do not necessarily indicate an acute issue.
B. Respirations are 40 breaths/minute is a critical finding, as this rapid respiratory rate suggests significant respiratory distress or worsening hypoxemia, which needs immediate intervention to prevent further complications.
C. An anterior-posterior diameter ratio of 1:1 (barrel chest) is a common finding in advanced COPD but does not indicate acute worsening.
D. Hyperresonance to percussion is typical in patients with COPD due to air trapping and does not suggest an immediate emergency.
E. Decreased tactile fremitus may occur in COPD due to increased air trapping but is not an urgent finding requiring immediate reporting.

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A client is admitted with a venous insufficiency of the right leg. What assessment findings does the nurse expect to find with this condition?

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Naxlex Comprehensive Predictor Exams

When performing a focused cardiac assessment on a newly admitted client, the nurse notes a heave on the left side of the chest. What can a heave signify?

Correct Answer is A

Explanation

The nurse obtains information when performing a focused assessment of a client with chronic obstructive pulmonary disease (COPD) who has been admitted with increasing dyspnea (shortness of breath) over the last 3 days. Which finding is most important to report to the health care provider?

Correct Answer is B

Explanation

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