Exhibits

The client with a cast must have a neurovascular assessment every hour for the first 24 hours and then every 4 to 8 hours after the cast has dried. Assessment of the skin, movement, sensation, pulses, pain and capillary refill are areas of concern.

When assessing the client's capillary refill status, what would be considered during the procedure? Select all that apply.

Capillary refill is the time it takes to return to the client's normal color after releasing pressure

Use your thumbnail and press the nailbed proximal to the injury

Pressure placed on the nailbed should cause blanching (pale)

Capillary refill is measured in seconds

Normal should be within 3 seconds or 5 in the older adult

Answer and Explanation

Correct Answer : B,C,D,E

A. Capillary refill is not the time it takes to return to the client's normal color after releasing pressure
B. Use your thumbnail and press the nailbed proximal to the injury: This is the correct technique for assessing capillary refill. You should press on the nailbed until it blanches and then release the pressure.
C. Pressure placed on the nailbed should cause blanching (pale): When pressure is applied to the nailbed, it should turn pale. This is known as blanching.
D. Capillary refill is measured in seconds: The time it takes for the nailbed to return to its normal color is measured in seconds.
E. Normal should be within 3 seconds or 5 in the older adult: A normal capillary refill time is generally considered to be within 3 seconds. However, in older adults, it may take up to 5 seconds for the nailbed to return to its normal color.

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Free Nursing Study Resources

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

Finding: Joint swelling

Rheumatoid arthritis

Rationale: Joint swelling is a common finding in rheumatoid arthritis (RA). RA typically causes inflammation in the joints, leading to swelling, pain, and stiffness. This is an indicator of the disease as it often involves multiple joints in a symmetrical pattern.

Finding: Heberden nodes

Not applicable

Rationale: Heberden nodes are not associated with rheumatoid arthritis but rather with osteoarthritis. These nodes are bony swellings that develop at the distal interphalangeal joints (DIP) of the fingers and are characteristic of osteoarthritis, not RA.

Finding: Symmetrical involvement

Rheumatoid arthritis

Rationale: Symmetrical joint involvement is a hallmark of rheumatoid arthritis. RA commonly affects joints on both sides of the body in a symmetrical fashion, which helps differentiate it from other forms of arthritis that may not have symmetrical patterns.

Finding: Pain increases with motion

Rheumatoid arthritis

Rationale: Pain that increases with motion is typical of rheumatoid arthritis. In RA, the affected joints often become more painful with activity, particularly when the joints are inflamed. This contrasts with some other forms of arthritis, where pain might be more constant or relieved by movement.

Finding: Fatigue and fever

Rheumatoid arthritis

Rationale: Fatigue and fever are systemic symptoms that can be associated with rheumatoid arthritis. RA is an autoimmune disease that can cause general malaise, fever, and significant fatigue along with joint symptoms.

Finding: Morning stiffness quickly resolves

Not applicable

Rationale: Morning stiffness that persists for a significant period is a characteristic feature of rheumatoid arthritis. The stiffness in RA typically does not quickly resolve and can last for several hours. Quick resolution of morning stiffness is more characteristic of other conditions, such as osteoarthritis.

Finding: Small joints of the hand

Rheumatoid arthritis

Rationale: Rheumatoid arthritis commonly affects the small joints of the hands, including the metacarpophalangeal joints (MCP) and proximal interphalangeal joints (PIP). This is a distinguishing feature of RA, as it often targets these joints in a symmetrical manner.

A. A minor variation B. Normal borborygmus sounds C. Possible renal artery stenosis D. Hyperactive bowel sounds

Correct Answer is C

Explanation

A. A minor variation would not typically produce a low-pitched blowing sound during auscultation. This sound is more concerning and usually suggests a vascular issue rather than a normal variation.
B. Normal borborygmus sounds are the typical gurgling or rumbling noises caused by the movement of gas and fluid in the intestines. They are not described as low-pitched blowing sounds and are heard more generally across the abdomen rather than specifically in the upper midline area.
C. A low-pitched blowing sound in the upper midline area could indicate possible renal artery stenosis, which is the narrowing of one or both renal arteries. This condition can cause turbulent blood flow, leading to an audible bruit during auscultation.
D. Hyperactive bowel sounds are usually high-pitched, frequent, and associated with increased peristalsis. They do not typically present as a low-pitched blowing sound, making this option incorrect.

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Naxlex Comprehensive Predictor Exams

Exhibits Nurse analyzes the assessment findings. Click to indicate which findings are indicative of rheumatoid arthritis or are not applicable to that disease. Each row must have only one response option selected.

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"B"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"B"},"G":{"answers":"A"}}

Explanation

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

Correct Answer is C

Explanation

While observing a client's face, which assessment finding requires immediate intervention by the nurse?

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?

To assess a client's pupillary reaction to accommodation, which action should the nurse take?

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.

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

Exhibits The nurse is assessing the client for bowel sounds. Which intervention(s) would be indicated to assess bowel sounds? Select all that apply.

The nurse assesses a client who comes to the clinic with neck stiffness and discomfort. Which finding of the cervical spine should the nurse inquire further about lifestyle habits?

When evaluating a client's rectal bleeding, which findings should the nurse document?