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 D

Explanation

A. Dimpled area above anus: This can be a sign of a pilonidal cyst, a condition where hair follicles become embedded under the skin.

B. Flap of tissue at sphincter: This could indicate haemorrhoids, swollen veins in the anus and rectum.

C. Hypotonic tone of the anal sphincter: Weak anal sphincter tone can lead to faecal incontinence.

D. Increased pigmentation and coarse skin: This is a normal finding, especially in adults. The perianal area can have a darker colour and thicker skin texture compared to other areas

A. Mother's use of alcohol, drugs, or cigarettes during pregnancy. B. List of achievement timeline for developmental milestones. C. A history of rubella, rubeola, or chicken pox. D. Reactions to any previous hospitalizations.

Correct Answer is D

Explanation

A. Mother's use of alcohol, drugs, or cigarettes during pregnancy: While this information might be relevant to the child's medical history, it's not directly related to planning care for the umbilical hernia repair surgery itself.

B. List of achievement timeline for developmental milestones: This information might be helpful for a general paediatric assessment, but it's not crucial for planning care specific to an umbilical hernia repair.

C. A history of rubella, rubeola, or chicken pox: Unless there are complications related to these illnesses, they are not directly relevant to the surgery.

D. Reactions to any previous hospitalizations: This information is vital. Knowing how the child reacted to previous hospitalizations (anaesthesia, medications, separation anxiety) can help the nurse anticipate potential challenges and develop strategies to create a positive experience for the child.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

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