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.

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. A peritoneal friction rub is a grating sound caused by inflamed surfaces of the peritoneum rubbing together.
B. Borborygmi refers to loud, gurgling bowel sounds often heard with increased intestinal motility.
C. Hypoactive bowel sounds are abnormally decreased or absent bowel sounds.
D. Borborygmi describes the normal sounds made by the movement of gas and fluid in the intestines.

A. "With aging, a large amount of subcutaneous fat is lost, which gives the appearance of decreased height." B. "With aging, the spine is not as flexible, which doesn't permit the individual to stand as tall." C. "With aging, the cartilage between the bones in the spine gets worn down, which causes decreased height." D. "With aging, thickening of the intervertebral disks occurs, which causes pressure breakdown of the spinal vertebrae."

Correct Answer is C

Explanation

A. Loss of subcutaneous fat might contribute to changes in appearance but is not primarily responsible for the decrease in height with aging.
B. Reduced spinal flexibility may contribute to posture changes but doesn’t sufficiently explain the decrease in height.
C. With aging, the intervertebral discs and cartilage between spinal bones wear down, leading to a decrease in height due to changes in the spine's structure.
D. Thickening of intervertebral discs is not a typical occurrence with aging and does not explain the decrease in height.

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The nurse has completed a peripheral vascular assessment on a client. Which of the following would the nurse document as expected findings?

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