An older male client reports to the nurse that his feet are cold.
Before covering the client’s feet, which assessment(s) should the nurse complete? Select all that apply.
Measure skin elasticity around the ankles.
Assess volume of the pedal pulses.
Palpate dorsal surface of feet for warmth.
Test feet for a positive Babinski reflex.
Observe color of the feet and toes.
Correct Answer : B,C,E
Choice A rationale
Measuring skin elasticity around the ankles is not directly related to assessing the cause of cold feet. It is more relevant for assessing hydration status and skin turgor.
Choice B rationale
Assessing the volume of the pedal pulses is crucial to determine if there is adequate blood flow to the feet.
Choice C rationale
Palpating the dorsal surface of the feet for warmth helps assess the temperature and circulation to the feet.
Choice D rationale
Testing for a positive Babinski reflex is not relevant to assessing cold feet. It is used to assess neurological function.
Choice E rationale
Observing the color of the feet and toes helps assess circulation and potential issues such as cyanosis or pallor.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["C","D"]
Explanation
Choice A rationale
The right side of the heart is not specifically associated with the loudest heart sounds for S1 or S213.
Choice B rationale
The center of the heart is not specifically associated with the loudest heart sounds for S1 or S213.
Choice C rationale
The apex of the heart is where S1 is loudest. S1 is caused by the closure of the mitral and tricuspid valves and is best heard at the apex.
Choice D rationale
The base of the heart is where S2 is loudest. S2 is caused by the closure of the aortic and pulmonic valves and is best heard at the base.
Choice E rationale
The left side of the heart is not specifically associated with the loudest heart sounds for S1 or S213.
Correct Answer is C
Explanation
Choice A rationale
Restricting activity to bed rest is important but not the most immediate intervention for a client with a high fever and pain during deep palpation.
Choice B rationale
Monitoring urinary output is important but not the most immediate intervention in this scenario.
Choice C rationale
Initiating NPO (nothing by mouth) status is crucial to prepare the client for potential surgical intervention, especially if the pain suggests an acute abdominal condition.
Choice D rationale
Obtaining an electrocardiogram is important but not the most immediate intervention for a client with abdominal pain and high fever.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.