The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

Absent deep tendon reflexes.

Capillary refill less than 3 seconds.

3+ peripheral dependent edema.

Oxygen saturation of 85%.

Answer and Explanation

The Correct Answer is D

A.   Absent deep tendon reflexes are not typically associated with nailbed clubbing. While reflexes may be diminished in some conditions, they are not commonly related to the pathophysiology behind clubbing.
B.   A capillary refill time of less than 3 seconds is a normal finding and does not align with clubbing, which often indicates chronic hypoxia or systemic conditions such as heart or lung disease.
C.   Peripheral dependent edema refers to swelling in the lower extremities, which can be associated with circulatory problems, but it is not directly linked to nailbed clubbing. Edema is more common in conditions like heart failure or kidney disease.
D.   A low oxygen saturation of 85% is consistent with conditions that cause chronic hypoxia, such as chronic lung disease or congenital heart disease. Chronic low oxygen levels can lead to nailbed clubbing as a compensatory response to inadequate oxygenation.

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Correct Answer is B

Explanation

A. While subjective data is important, it should be categorized appropriately based on relevance to the diagnosis, not just placed in the notes section without context.
B. Documenting the client’s history directly related to the current admission diagnoses ensures the information is relevant and addresses the issue at hand. It helps prioritize concerns specific to the new onset seizures.
C. Recording at the bedside can be useful for accuracy but is not as effective for thoroughness as
entering information directly in the client’s electronic medical record with appropriate organization.
D. Documenting assessment findings at the nursing station might delay real-time recording and cause the information to be less accurate, especially if not recorded immediately after assessment.

A. Record the findings as a normal response. B. Determine if the client has a history of heart disease. C. Obtain the client's blood pressure. D. Compare the apical pulse force to the carotid pulse force.

Correct Answer is B

Explanation

A. If the apical impulse is more vigorous than expected, it may indicate an abnormal finding, such as hyperdynamic circulation or heart failure. The nurse should not simply record this without further investigation.
B. It is important to investigate whether the client has a history of heart disease, as conditions like left ventricular hypertrophy, heart failure, or valvular heart disease could cause changes in the apical impulse. This provides context for understanding the findings.
C. Obtaining the client’s blood pressure is important in assessing cardiovascular health, but the most immediate response to a more vigorous apical impulse would be to explore the potential cause, including heart disease, rather than simply measuring blood pressure.
D. Comparing the apical pulse to the carotid pulse may help assess if the increased pulse force is generalized or localized, and whether it might be a sign of circulatory changes. This would help clarify whether the finding is normal or indicative of pathology.

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The nurse assesses that a client has nailbed clubbing. Which additional information is consistent with this finding?

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Naxlex Comprehensive Predictor Exams

The nurse is obtaining a health history for a client being admitted for new onset seizures. Which action should the nurse implement to accurately record the health history findings?

Correct Answer is B

Explanation

During the precordium assessment, the nurse palpates the apical impulse of a client on the 5th intercostal space left mid-clavicular line. The pulse is more vigorous than expected. Which action should the nurse take in response to this finding?

Correct Answer is B

Explanation

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