The nurse assesses a client's fingernails as seen in the photo. How should the nurse document the findings?

Fingernail pitting present.

Nail care needed.

Capillary refill less than 3 seconds.

Nailbeds pink.

Answer and Explanation

The Correct Answer is D

Rationale:
A. Fingernail pitting present: Fingernail pitting appears as small depressions or pits on the nail surface, often seen in psoriasis. The client's nails in the photo are smooth and intact, showing no signs of pitting, so this option is not accurate.

B. Nail care needed: Nail care would be documented if there were overgrown, broken, dirty, or neglected nails. The nails shown are clean and neatly maintained, meaning nail care is not an immediate need for this client.

C. Capillary refill less than 3 seconds: Capillary refill time measures circulation but is not assessed just by observing nail color. It requires pressing the nail and timing how quickly color returns, which is not part of this static assessment.

D. Nailbeds pink: Pink nailbeds indicate good peripheral circulation and oxygenation. In the photo, the client's nailbeds are visibly pink without cyanosis, discoloration, or pallor, making this the correct documentation of the findings.

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Correct Answer is B

Explanation

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.

A. "Have you ever considered being evaluated for a hearing aid?" B. "Do you have a history of ear infections?" C. "Is this hearing loss accompanied by any loss of balance?" D. "How is this hearing loss interfering with your daily activities of living?"

Correct Answer is D

Explanation

Rationale:
A. "Have you ever considered being evaluated for a hearing aid?": Suggesting a hearing aid too early may feel dismissive and presumes a diagnosis without a full assessment. First, the nurse needs to understand the impact and specifics of the hearing loss before recommending interventions like hearing aids.

B. "Do you have a history of ear infections?": A history of ear infections is relevant because recurrent infections can lead to conductive hearing loss. However, the pattern described—garbled words and missed sentence endings—suggests possible sensorineural hearing loss (presbycusis), making a broader functional assessment more appropriate first.

C. "Is this hearing loss accompanied by any loss of balance?": Hearing loss combined with balance issues could suggest vestibular involvement. However, in the absence of the client mentioning dizziness or falls, the more pressing need is to assess how hearing difficulties are impacting daily functioning and quality of life.

D. "How is this hearing loss interfering with your daily activities of living?": Understanding how the hearing loss affects activities of daily living helps the nurse assess the severity and functional impact. This client-centered approach guides both the urgency of intervention and the planning of supportive resources to enhance the client’s quality of life.

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The nurse assesses a client's fingernails as seen in the photo. How should the nurse document the findings?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While completing a health assessment for a client with peripheral vascular disease (PVD), which assessment technique is most important for the nurse to implement?

Correct Answer is B

Explanation

An older adult client reports noticing an increased difficulty hearing over the past year. The client explains that words often sound garbled and the end of sentences are often missed. Which follow up question is best for the nurse to ask?

Correct Answer is D

Explanation

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