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.

Test feet for a positive Babinski reflex.

Observe color of the feet and toes.

Assess volume of the pedal pulses.

Palpate dorsal surface of feet for warmth.

Measure skin elasticity around the ankles.

Answer and Explanation

Correct Answer : B,C,D

A. Test feet for a positive Babinski reflex. This assesses neurological function but is not directly related to cold feet.

B. Observe color of the feet and toes. This is important as changes in color can indicate poor circulation.

C. Assess volume of the pedal pulses. This is important to assess the adequacy of blood flow to the feet.

D. Palpate dorsal surface of feet for warmth. This directly assesses temperature and potential circulation issues.

E. Measure skin elasticity around the ankles. This assesses hydration status but is less relevant to cold feet.

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Correct Answer is C

Explanation

A. Glasgow Coma Scale (GCS) of 15. The GCS is a measure of consciousness and not specific to pupil assessment. It assesses eye opening, verbal response, and motor response.

B. Pupils equal, round, reacts to light, and accommodation (PERLA). This notation is incorrect because the nurse only assessed for light reaction, not accommodation.

C. Pupils equal, round, reacts to light (PERRL). This is the correct documentation based on the observed findings.

D. Neurological status intact. This is a general statement and does not specifically document the pupil findings.

A. ever had problems with your blood sugar?" B. been sleeping well?" C. been depressed lately?" D. had anything to eat in the last 24 hours?"

Correct Answer is B

No explanation

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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

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Correct Answer is C

Explanation

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