To compare arterial circulation in a client's lower extremities, which assessment should the nurse complete?

Compress the tissue around the ankles.

Observe plantar flexion and dorsiflexion.

Palpate the volume of the pedal pulses.

Stroke the soles and note toe movement.

Answer and Explanation

The Correct Answer is C

A. Compress the tissue around the ankles: Compressing the tissue around the ankles can assess for edema but does not provide direct information about arterial circulation.

B. Observe plantar flexion and dorsiflexion: Observing plantar flexion and dorsiflexion assesses motor function and muscle strength but does not directly assess arterial circulation.

C. Palpate the volume of the pedal pulses: Palpating pedal pulses is a direct method to assess arterial blood flow to the lower extremities. It provides information about the strength and quality of arterial circulation.

D. Stroke the soles and note toe movement: Stroking the soles and noting toe movement is the Babinski reflex test, which assesses neurological function, not arterial circulation.

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Correct Answer is C

Explanation

A. Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly. This action is used to assess breath sounds, not tactile fremitus.

B. Looking at the client from the side, observe the size and shape of the chest wall. This action helps in assessing the general appearance and shape of the chest but does not assess tactile fremitus.

C. Place the palm of the hand on the chest wall to feel vibrations while the client speaks. This is the correct technique to assess tactile fremitus. Increased fremitus can indicate consolidation, as in pneumonia.

D. Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation. This action is associated with palpating for crepitus, not assessing tactile fremitus.

A. Stand behind the client to avoid intimidation. B. Turn on overhead lights while giving instructions. C. Provide handouts written at a 12th grade reading level. D. Use background music to promote relaxation.

Correct Answer is B

Explanation

A. Stand behind the client to avoid intimidation. This is not an appropriate teaching strategy. Standing behind a client can actually increase intimidation and anxiety, as it does not allow for direct eye contact and clear communication.

B. Turn on overhead lights while giving instructions. Proper lighting is essential for older adults, who may have visual impairments. Turning on overhead lights ensures that the client can clearly see the materials and the nurse, enhancing understanding and engagement during the teaching session.

C. Provide handouts written at a 12th grade reading level. Handouts for patient education should be written at a lower reading level, generally around the 5th to 6th grade level, to ensure comprehension by a broad audience, including those with limited literacy skills. A 12th grade reading level is too high for effective patient education for most adults.

D. Use background music to promote relaxation. Background music can be distracting rather than relaxing during educational sessions, especially for older adults who may have hearing impairments or cognitive issues. Clear and focused communication is more effective without additional auditory distractions.

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To compare arterial circulation in a client's lower extremities, which assessment should the nurse complete?

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