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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is B

Explanation

Answer: B. Wandering behavior with flat affect.

Rationale:

A. Ambulatory and disoriented to place:
This documentation suggests that the client is physically able to walk but does not adequately capture the behavioral aspect of the observation. While the client may be ambulatory, merely stating disorientation does not convey the lack of engagement or emotional response, which is crucial in understanding the client's mental state and overall condition.

B. Wandering behavior with flat affect:
This option accurately reflects the observed behavior of the client. "Wandering behavior" captures the aimless walking, while "flat affect" describes the lack of emotional expression indicated by the blank stare. This documentation provides a clearer picture of the client's mental status, which is vital for further assessment and intervention.

C. Appears confused and depressed:
While confusion may be a relevant aspect of the client's condition, this statement lacks specificity regarding the observed behaviors. Depression cannot be accurately concluded from the blank expression alone, as it may not reflect sadness or mood but rather a cognitive or perceptual issue. More objective descriptors would enhance the clarity of the documentation.

D. Demonstrates signs of early dementia:
This option makes a definitive statement about the possibility of early dementia without sufficient evidence from the observation. While aimless walking and a blank expression can be associated with cognitive decline, diagnosing dementia requires comprehensive assessment and evaluation beyond a single observation. This phrasing could mislead healthcare providers regarding the client’s condition and may lead to premature conclusions about the client’s cognitive health.

A. Sharp, severe pain. B. Audible thud without pain. C. Rigidity and firmness. D. Rebound tenderness.

Correct Answer is A

Explanation

A) Sharp, severe pain:
Percussion of the costovertebral angle (CVA) elicits sharp, severe pain in a client with pyelonephritis. This response indicates inflammation of the kidney and surrounding tissues, which is typical in pyelonephritis.

B) Audible thud without pain:
An audible thud without pain is a normal finding when percussing the CVA and would not be expected in a client with pyelonephritis.

C) Rigidity and firmness:
Rigidity and firmness may be related to muscle guarding or abdominal assessment findings, but they are not specific to CVA percussion and pyelonephritis.

D) Rebound tenderness:
Rebound tenderness is a sign of peritoneal irritation and is assessed by pressing on the abdomen and quickly releasing. It is not the typical finding associated with CVA percussion in pyelonephritis.

View Question and Answer

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

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

The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)?

Correct Answer is B

Explanation

Rationale:

The nurse is performing an admission assessment for a client with pyelonephritis who has urgency and burning while urinating. Which finding indicates an expected response when the nurse percusses the costovertebral angle?

Correct Answer is A

Explanation

A client who is admitted for an acute stroke reports the onset of a burning sensation in the hands and legs. Which action should the nurse implement to identify additional findings that are consistent with the client's paresthesia?

The nurse asks a female client about the proverb "Glass Houses," and she replies, "It will break the windows." Which conclusion should be documented about this client's response?

An adult client presents with gnawing epigastric pain. The pain is worse when the client is hungry and abates after eating something. Which problem do these symptoms suggest?

The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you..."

The nurse observes the presence of brittle, concave curves to the nails of a client on assessment. Which information should the nurse obtain from the client that may explain the appearance of the nails?

When family members express their concern about their father's recent memory loss, which assessment should the nurse suggest?

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?