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 B

Explanation

A. Hepatomegaly refers to an enlarged liver.
B. Hematopoiesis is the process of blood cell formation that occurs primarily in the bone marrow.
C. Osteogenesis is the process of bone formation.
D. Splenomegaly refers to an enlarged spleen.

A. Glasgow Coma Scale B. Complete neurological examination C. Muscular examination D. Neurologic recheck examination

Correct Answer is B

Explanation

A. The Glasgow Coma Scale assesses a patient's level of consciousness, not specifically limb weakness.
B. A complete neurological examination would involve assessing cranial nerves, motor and sensory functions, reflexes, coordination, and gait, which are essential when a client presents with unilateral weakness in the arm and leg.
C. A muscular examination might focus more on muscle strength and tone but might not cover the breadth of neurological assessment needed in this scenario.
D. Neurologic recheck examination suggests a reassessment after an initial neurological exam but doesn’t specify the need for a comprehensive evaluation.

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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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Naxlex Comprehensive Predictor Exams

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