During a visit to the clinic, a patient complains that her legs feel heavy in the calf. The nurse assesses that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings?

Deep-vein thrombophlebitis

Varicose veins

Peripheral artery disease

Chronic lymphedema

Answer and Explanation

The Correct Answer is B

Choice A reason: Deep-vein thrombophlebitis involves deep vein inflammation and clotting, causing pain, swelling, and warmth, but not typically visible dilated veins. The described tortuous veins are superficial, not deep, making this an incorrect diagnosis for the findings.

Choice B reason: Varicose veins are dilated, tortuous superficial veins, often in the lower legs, causing heaviness or aching. These result from venous insufficiency, leading to blood pooling, which matches the patient’s visible veins and symptoms, making this correct.

Choice C reason: Peripheral artery disease causes reduced arterial blood flow, leading to pain, pallor, or claudication, not dilated veins. The visible tortuous veins suggest a venous issue, not arterial, making this an incorrect condition for the findings.

Choice D reason: Chronic lymphedema causes swelling due to lymphatic fluid accumulation, typically without dilated veins. The patient’s tortuous veins and heaviness point to venous pathology, not lymphatic, making this an incorrect diagnosis for the described symptoms.

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Correct Answer is C

Explanation

Choice A reason: Standing 6 feet away is too far for a whisper test, which is typically done at 1–2 feet. Whispering words for repetition is the standard method, so this is incorrect for hearing assessment.

Choice B reason: Occluding one ear tests unilateral hearing but isn’t the primary voice test method. Whispering random words and checking repetition directly assesses hearing, so this is not the best action.

Choice C reason: Whispering random numbers, words, or letters at 1–2 feet and asking the patient to repeat them is the standard voice test for hearing. This method is effective, making it the correct choice.

Choice D reason: Shielding lips muffles sound unnecessarily and prevents lip-reading, which isn’t the goal. Clear whispering and repetition test auditory function, so this is incorrect for the voice test.

A. Positive Homan sign B. Lack of coordination C. Positive Romberg sign D. Ataxia

Correct Answer is C

Explanation

Choice A reason: Homan sign tests for deep vein thrombosis, not balance. Swaying with eyes closed indicates a positive Romberg sign, so this is incorrect for the documented finding.

Choice B reason: Lack of coordination is vague and not specific to the Romberg test, which assesses proprioception. Positive Romberg sign describes the sway, so this is incorrect for documentation.

Choice C reason: A positive Romberg sign is documented when a patient sways or loses balance with eyes closed, indicating proprioceptive or cerebellar issues. This is the correct term for the finding.

Choice D reason: Ataxia describes general movement, not the specific Romberg test outcome. Swaying in this context is a Romberg sign, so this is incorrect for the nurse’s documentation.

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During a visit to the clinic, a patient complains that her legs feel heavy in the calf. The nurse assesses that the patient has dilated, tortuous veins apparent in her lower legs. Which condition is reflected by these findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In performing a voice test to assess hearing, which of these actions would the nurse perform?

Correct Answer is C

Explanation

When the nurse asks an older patient to stand with feet together and arms at his side with his eyes closed, he starts to sway and moves his feet farther apart. How should the nurse document this finding?

Correct Answer is C

Explanation

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