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 B

Explanation

A. "I am sorry you feel that way. Perhaps you'd like to return when you have more time."

While this response acknowledges the client's feelings, it may inadvertently dismiss the client's concerns and fail to address the immediate need for treatment. It's important for the nurse to engage with the client and explore their concerns rather than suggesting they come back later.

B. "You sound angry. Would you like to tell me about it?"

This response demonstrates empathy and acknowledges the client's emotions. By inviting the client to express their feelings further, the nurse opens the door for communication and understanding. It allows the nurse to explore the underlying reasons for the client's frustration and address their concerns.

C. Ignore the angry outburst and continue with the history questions.

Ignoring the client's emotional outburst may cause the client to feel unheard or invalidated, potentially escalating the situation further. It's essential for the nurse to address the client's concerns and emotions to maintain a therapeutic relationship and provide effective care.

D. Move closer and place a hand on the client's shoulder to demonstrate concern.

While physical touch can be comforting for some individuals, it's important to consider the client's preferences and boundaries, especially in a situation where the client is expressing frustration or impatience. Approaching the client physically without consent may not be appropriate and could further exacerbate the situation.

A. Blood urea nitrogen (BUN). B. Glucose. C. White blood cell count (WBC). D. Hematocrit.

Correct Answer is D

Explanation

A. Blood urea nitrogen (BUN): Elevated BUN can indicate kidney problems, but it's not the primary test for melena (black, tarry stools) which suggests upper gastrointestinal bleeding.

B. Glucose: Glucose levels might be abnormal in some conditions that can cause bleeding, but it's not the most specific test for melena.

C. White blood cell count (WBC): WBC might be elevated in response to infection or inflammation, but it's not the most specific test for melena.

D. Hematocrit: Hematocrit measures the percentage of red blood cells in the blood. Melena can indicate significant blood loss, and monitoring hematocrit helps assess the severity of bleeding and potential need for blood transfusions.

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

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Naxlex Comprehensive Predictor Exams

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Explanation

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Correct Answer is D

Explanation

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