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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Correct Answer is D

Explanation

A. The basal ganglia are involved in motor control and learning but not specifically in controlling voluntary movement.
B. Motor pathways do not directly synapse in the thalamus; the thalamus serves as a relay station for sensory information.
C. The cerebellum is primarily involved in coordination, balance, and muscle control, not in speech and emotions.
D. The hypothalamus plays a crucial role in regulating body temperature, controlling hunger, thirst, fatigue, and regulating sleep cycles.

A. Listen to the client's speech. B. Ask them to read a Snellen chart. C. Ask them to identify scented aromas. D. Ask them to clench their teeth.

Correct Answer is D

Explanation

A. Listening to speech primarily involves cranial nerves related to speech production (e.g., CN V, CN VII, CN XII) but not specifically for CN V.
B. Reading a Snellen chart assesses visual acuity, primarily involving cranial nerve II (optic nerve).
C. Identifying scented aromas involves olfactory nerve (cranial nerve I) assessment.
D. Asking the client to clench their teeth evaluates the function of the muscles of mastication, which is controlled by cranial nerve V (trigeminal nerve).

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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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