The nurse has completed a peripheral vascular assessment on a client. Which of the following would the nurse document as expected findings?
Capillary refill <5 seconds.
Radial pulses 2+ with regular rate and rhythm bilaterally.
Feet pale and cool to the touch.
Right ankle 1+ edema with no perceptible swelling of the leg.
The Correct Answer is B
A. A capillary refill of less than 5 seconds is considered normal.
B. Radial pulses 2+ with regular rate and rhythm bilaterally indicate good peripheral circulation.
C. Feet that are pale and cool to the touch could indicate decreased perfusion or vascular compromise.
D. Right ankle 1+ edema may suggest some fluid retention but no perceptible swelling of the leg indicates relatively normal findings in that area.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
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Correct Answer is B
Explanation
A. Timing for testicular examination isn't as crucial as recognizing changes in the testicles. While showering might facilitate the exam, it's not the only appropriate time.
B. Noticing an enlargement or painless lump is a crucial sign that requires immediate medical attention for evaluation.
C. Performing a testicular examination once a week might not be necessary for most individuals. Monthly self-examination is often recommended.
D. Describing the testicle's normal characteristics is helpful, but recognizing changes such as lumps or enlargements is more critical for self-examination.
Correct Answer is A
Explanation
A. Vertigo is the sensation of spinning or movement when stationary and is often associated with inner ear problems.
B. Seizure activity involves abnormal electrical activity in the brain and might present with various symptoms but not necessarily the feeling of spinning.
C. Dizziness is a more general term that can include feelings of light-headedness or unsteadiness without a specific spinning sensation.
D. Syncope refers to fainting or loss of consciousness due to decreased blood flow to the brain, not the sensation of spinning.
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