A homeless male client with a history of alcohol abuse had a cerebrovascular accident (CVA) 10 years ago that resulted in left hemiparesis. Today he is reporting pain in his left leg, is afebrile, has 4+ pitting edema in the lower left leg, and minimal swelling of the right leg. Which action should the nurse implement first?

Complete a mental status exam.

Obtain a blood alcohol level.

Inspect legs for infection or trauma.

Inquire about dietary salt intake.

Answer and Explanation

The Correct Answer is C

A.   The client’s current symptoms—pain, significant leg edema, and swelling—are more pressing and suggest a need to evaluate the physical cause of these symptoms rather than focusing immediately on mental status.
B.   Obtaining a blood alcohol level might be relevant if there is a suspicion that recent alcohol use is contributing to the client’s condition or affecting his overall health. However, the primary concern in this case is the significant edema and pain in the left leg.
C.   This is the most pertinent action to take first. The client’s symptoms of severe edema and pain in one leg, along with a history of CVA and alcohol abuse, raise concerns about possible causes such as deep vein thrombosis (DVT), infection, or trauma. Inspecting the legs for signs of infection or trauma (bruising, cuts) is crucial to determine the underlying cause of the symptoms and guide appropriate treatment.

D.   While excessive salt intake can contribute to fluid retention and edema, the degree of swelling described (4+ pitting edema) and the localized nature of the problem in the left leg make it less likely that dietary salt alone is the cause.

Nursing Test Bank

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Correct Answer is B

Explanation

A. Skin turgor assesses skin elasticity and hydration, which is more indicative of general hydration status rather than specific types of insufficiency. While poor skin turgor might be observed in various conditions, it does not specifically differentiate between venous and arterial ulcers.
B. The location and appearance of the ulcer can provide significant clues about its etiology. Venous ulcers often appear on the lower legs, particularly around the medial malleolus (inside of the ankle), and tend to have irregular, shallow, and often wet or weepy edges.
C. Changes in color upon movement can provide insight into the type of insufficiency. For arterial ulcers, the leg may appear pale or blanched when elevated and may develop a reddish or purple color when lowered due to poor blood flow.
D. Measuring joint range of motion assesses flexibility and mobility rather than the type of ulcer. While joint mobility issues can be associated with various conditions, including those affecting the vascular system, it does not directly help in distinguishing between venous and arterial insufficiency ulcers.

A. Soft tissue. B. Gas. C. Intestinal mass. D. Full bladder.

Correct Answer is B

Explanation

A. Soft tissue, such as the liver or spleen, typically produces a dull sound on percussion, not a high- pitched musical sound. Soft tissue is more associated with a dullness because it is denser compared to the surrounding air or fluids.
B. Gas in the gastrointestinal tract often produces a musical or high-pitched sound on percussion, known as tympany. This sound occurs because gas is less dense than other abdominal contents and resonates with a high pitch. Tympany is the most common sound heard when percussing over the stomach and intestines.
C. An intestinal mass, depending on its size and location, may produce a dull or a combination of dull and tympanic sounds. However, it is not typically associated with a high-pitched musical sound. Percussion over an intestinal mass would likely be dull rather than musical.
D. A full bladder typically produces a dull sound on percussion, not a musical high-pitched sound. A dull sound indicates the presence of a solid or fluid-filled structure, such as a full bladder.

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Naxlex Comprehensive Predictor Exams

The nurse is assessing an ulcer on a client's lower extremity, which is likely the result of either venous or arterial insufficiency. Which assessment technique should the nurse use to differentiate the pathophysiology causing the ulcer?

Correct Answer is B

Explanation

While percussing the abdomen of an adult male client, the nurse encounters a musical high-pitched sound. Which does this finding indicate?

Correct Answer is B

Explanation

A 75-year-old client with a recent history of a cerebrovascular accident (CVA) presents with right hemiparesis. The nurse tests the deep tendon reflexes on the right side and elicits a brisk 4+ response. Which interpretation of this finding is accurate?

The nurse is completing an assessment for a client with uncontrolled diabetes mellitus (DM) who came to the clinic reporting frequent, painful urination. Which screening test should the nurse perform first?

The nurse auscultates the precordium of a client who is diagnosed with mitral valve regurgitation and hears a grade IV systolic murmur. When documenting the comparison of systolic murmurs, which characteristics should the nurse use to support this systolic finding?

In assessing a client's sensory nerve function, the nurse prepares to assess the client's response to temperature. What action should the nurse include during this assessment?

The nurse assesses a male client who is brought to the emergency department (ED) by his family who believes he is having a heart attack. Which finding is the best indicator that a client is experiencing an acute myocardial infarction (AMI)?

When entering a male client's room, the nurse observes that he is splinting his chest with a pillow. Which follow-up assessment should the nurse complete?

The nurse has just completed palpation maneuvers for lymph nodes on an older adult female client. Which findings are considered normal for this elderly client?

The nurse assesses a client with a sleep pattern disturbance. In developing a plan of care, what assessment data should the nurse obtain first?