The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you

ever had problems with your blood sugar?"

been sleeping well?"

been depressed lately?"

had anything to eat in the last 24 hours?"

Answer and Explanation

The Correct Answer is B

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Correct Answer is C

Explanation

A. Notify the healthcare provider. While notifying the healthcare provider is important, it is not the immediate action to take.

B. Apply warm blankets to both feet. Warm blankets can improve circulation but are not the immediate diagnostic step.

C. Use a Doppler ultrasonic stethoscope. This is the best choice because a Doppler can help detect pulses that are not palpable, providing immediate diagnostic information.

D. Palpate pulse points with legs dependent. Changing the position of the legs might help but is not as effective as using a Doppler for immediate assessment.

A. Test feet for a positive Babinski reflex. B. Observe color of the feet and toes. C. Assess volume of the pedal pulses. D. Palpate dorsal surface of feet for warmth. E. Measure skin elasticity around the ankles.

Correct Answer is ["B","C","D"]

Explanation

A. Test feet for a positive Babinski reflex. This assesses neurological function but is not directly related to cold feet.

B. Observe color of the feet and toes. This is important as changes in color can indicate poor circulation.

C. Assess volume of the pedal pulses. This is important to assess the adequacy of blood flow to the feet.

D. Palpate dorsal surface of feet for warmth. This directly assesses temperature and potential circulation issues.

E. Measure skin elasticity around the ankles. This assesses hydration status but is less relevant to cold feet.

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The nurse is performing an initial assessment of a client who has an expressionless facial affect, slurred speech, and red conjunctivae. Which question should the nurse ask first? "Have you

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Naxlex Comprehensive Predictor Exams

While performing a physical assessment, the nurse is unable to palpate the client's pedal pulses. Which action should the nurse take?

Correct Answer is C

Explanation

An older male client reports to the nurse that his feet are cold. Before covering the client's feet, which assessment(s) should the nurse complete? Select all that apply.

Correct Answer is ["B","C","D"]

Explanation

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

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