Exhibits

The nurse is admitting the client to the stroke unit and preparing to complete a focused neurological assessment.
Which assessment(s) should the nurse conduct? Select all that apply.

Rationale:
A. Heartburn occurs when lying down at night: Lying flat increases intra-abdominal pressure and reduces gravity’s assistance in keeping stomach contents from refluxing into the esophagus. Nighttime heartburn is a classic symptom of gastroesophageal reflux disease (GERD) and is important for the nurse to further assess when evaluating the client’s condition.

B. Small frequent meals cause heartburn to worsen: Small, frequent meals are generally recommended for clients with GERD to reduce gastric distention and minimize reflux episodes. Worsening heartburn after small meals would not be typical and suggests another gastrointestinal issue rather than straightforward reflux.

C. Hyperactive bowel sounds are present in all quadrants: Hyperactive bowel sounds are more commonly associated with gastrointestinal disorders like diarrhea or early bowel obstruction, not GERD. GERD primarily affects the esophagus and upper gastric system without typically altering bowel sound patterns.

D. Bowel movements are light grey and chalky: Light grey or chalky stools indicate possible biliary obstruction or liver dysfunction, not gastroesophageal reflux. GERD symptoms are primarily upper gastrointestinal in nature and do not typically affect the color or characteristics of bowel movements.

Rationale:
A. Document thickened toe nails: Thickened toenails can be a sign of poor circulation associated with PVD, but documenting this alone does not provide critical information about current perfusion status. While important, it is less urgent compared to assessing the functionality of blood flow through distal pulses.

B. Palpate and document quality of distal pulses: Palpating distal pulses, such as dorsalis pedis and posterior tibial, is crucial to assess arterial blood flow to the extremities. In clients with PVD, weak or absent pulses can indicate worsening ischemia, making this assessment vital for early intervention and monitoring disease progression.

C. Measure ankle-brachial index (ABI): ABI is a non-invasive diagnostic test that measures the ratio of ankle to arm blood pressure to confirm PVD severity. It is a key diagnostic tool for PVD and provides objective data on the severity of arterial disease. However, in the context of a routine health assessment, palpating distal pulses offers immediate, albeit subjective, information about perfusion. While ABI is important, pulse assessment is often the initial and most readily available technique during a physical exam.

D. Measure and record dependent ankle edema: Dependent edema is more indicative of venous insufficiency rather than arterial PVD. Although documenting edema can assist in the overall vascular assessment, it does not directly evaluate arterial perfusion, which is the primary concern in PVD clients.