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.
Observe color of the feet and toes.
Assess volume of the pedal pulses.
Test feet for a positive Babinski reflex.
Measure skin elasticity around the ankles.
Correct Answer : A,B,C
A. Palpating the dorsal surface of the feet for warmth helps assess peripheral circulation and whether the cold sensation is due to poor blood flow.
B. Observing the color of the feet and toes is crucial as changes in color can indicate circulation issues, such as cyanosis or pallor, which can be related to the sensation of coldness.
C. Assessing the volume of the pedal pulses helps determine the adequacy of blood flow to the feet. Weak or absent pulses could indicate peripheral vascular problems contributing to the cold sensation.
D. The Babinski reflex is not relevant for assessing cold feet. It is typically assessed in infants or individuals with neurological concerns rather than for peripheral circulation issues.
E. Measuring skin elasticity around the ankles is useful for assessing hydration status and potential edema but is not directly related to assessing the cause of cold feet.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. A BMI of 32 kg/m² falls into the category of obesity. Obesity is associated with an increased risk of health issues such as cardiovascular disease, diabetes, and hypertension, making it a serious threat to overall well-being.
B. Undernutrition is indicated by a BMI below 18.5 kg/m². A BMI of 32 kg/m² does not suggest undernutrition or risk for malnutrition.
C. A BMI of 32 kg/m² is above the normal range of 18.5 to 24.9 kg/m², indicating that the weight is not appropriate for height. It suggests that the client is overweight or obese rather than being in good general health.
D. While extreme obesity (BMI ≥ 40 kg/m²) is a serious condition with a high risk for multiple co-morbidities, a BMI of 32 kg/m² is categorized as obesity rather than extreme obesity. Extreme obesity typically has a higher BMI threshold.
Correct Answer is D
Explanation
A. Telephoning a family member is a complex task that involves communication skills and cognitive abilities, which, while important, are more related to instrumental activities of daily living (IADLs) rather than basic ADLs.
B. Reading a short paragraph is a cognitive task and does not directly relate to the physical ability to perform basic ADLs.
C. Sorting a collection of socks is a useful task for assessing cognitive function and organization but is not as directly related to the physical tasks of daily living.
D. Opening a bar soap package is a basic task that directly assesses the client's ability to perform an activity of daily living, specifically related to self-care and personal hygiene. This task involves fine motor skills, hand-eye coordination, and the ability to complete a simple self-care activity, making it a practical choice for evaluating ADL capabilities.
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