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.

Palpate dorsal surface of feet for warmth.

Test feet for a positive Babinski reflex.

Measure skin elasticity around the ankles.

Assess volume of the pedal pulses.

Observe color of the feet and toes.

Answer and Explanation

Correct Answer : A,D,E

A) Palpate dorsal surface of feet for warmth:
Assessing the temperature of the dorsal surface of the feet helps determine peripheral circulation and can indicate whether the feet are indeed cold. Cold feet may suggest poor peripheral perfusion or circulation issues, which require further assessment.

B) Test feet for a positive Babinski reflex:
The Babinski reflex is typically tested to assess upper motor neuron dysfunction and is not directly relevant to evaluating the complaint of cold feet.

C) Measure skin elasticity around the ankles:
Measuring skin elasticity around the ankles may be relevant for assessing skin turgor and hydration status but is not specifically related to evaluating the client's complaint of cold feet.

D) Assess volume of the pedal pulses:
Assessing the volume of pedal pulses provides information about peripheral perfusion and circulation. Diminished or absent pedal pulses may indicate peripheral vascular disease or other circulatory issues contributing to cold feet. It's essential to evaluate the strength and symmetry of pedal pulses to determine peripheral vascular status.

E) Observe color of the feet and toes:
While observing the color of the feet and toes is important for assessing circulation and perfusion, it is not specific to evaluating the client's complaint of cold feet. However, color changes, such as pallor or cyanosis, may provide additional information about peripheral circulation and require further assessment.

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Correct Answer is C

Explanation

A) Looking at the client from the side, observe the size and shape of the chest wall:
This action is more related to inspecting the physical appearance and symmetry of the chest wall but does not assess tactile fremitus.

B) Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation:
This action may be more relevant for assessing subcutaneous emphysema (crepitus) but is not the correct method for assessing tactile fremitus.

C) Place the palm of the hand on the chest wall to feel vibrations while the client speaks:
This is the correct action to assess tactile fremitus. By placing the palm of the hand on various areas of the chest wall while the client repeats a phrase such as "ninety-nine," the nurse can feel for vibrations. Increased tactile fremitus can indicate consolidation, as seen in pneumonia.

D) Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly:
This action involves auscultation, which is important for assessing breath sounds but does not assess tactile fremitus directly.

A. Hypogastric region. B. Epigastric region. C. Umbilical region. D. Hypochondriac region.

Correct Answer is B

Explanation

A) Hypogastric region:
The hypogastric region, also known as the suprapubic region, is located below the umbilical region and above the pubic area. Pain in the hypogastric region would be lower in the abdomen than described.

B) Epigastric region:
The epigastric region is located in the upper central part of the abdomen, just below the xiphoid process. Pain localized in the middle section of the abdomen below the xiphoid process is described as occurring in the epigastric region.

C) Umbilical region:
The umbilical region is located around the navel (belly button). Pain in this area would be centered around the umbilicus and not higher up near the xiphoid process.

D) Hypochondriac region:
The hypochondriac regions are located on either side of the epigastric region and below the ribcage. Pain in the hypochondriac region would be more lateral and not centrally located below the xiphoid process.

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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.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In assessing tactile fremitus in the client with suspected pneumonia, the nurse should perform which action?

Correct Answer is C

Explanation

A client reports experiencing stomach pain and it is localized in the middle section of the abdomen below the xiphoid process. The nurse should describe the pain as occurring in which region of the abdomen?

Correct Answer is B

Explanation

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