When assessing a client's lower extremities, which finding requires immediate intervention by the nurse?

Multiple varicosities on both thighs.

Lack of hair growth on both lower legs.

Stage 2 pressure injury over the left ankle.

Right calf swelling and tenderness.

Answer and Explanation

The Correct Answer is D

A.   Varicosities, or varicose veins, are dilated veins that appear on the skin and are often associated with venous insufficiency. While they can be symptomatic and require management, they typically do not constitute an immediate medical emergency. Varicosities are generally managed with lifestyle changes, compression therapy, or medical procedures, but they are not usually life-threatening.
B.   Lack of hair growth on the lower legs can indicate poor circulation, commonly seen in conditions like peripheral arterial disease (PAD). While it is a concerning finding and suggests potential arterial insufficiency, it is not usually an immediate emergency.
C.   A Stage 2 pressure injury is characterized by partial-thickness loss of dermis, presenting as a shallow, open ulcer with a pink wound bed. While it requires attention to prevent progression and manage the wound, it is not an immediate emergency compared to other findings that suggest acute complications.

D.   Right calf swelling and tenderness are critical findings that could indicate a deep vein thrombosis (DVT), which is a serious condition where a blood clot forms in a deep vein, usually in the leg. DVT can lead to life-threatening complications such as pulmonary embolism if the clot dislodges and travels to the lungs.

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Free Nursing Study Resources

Correct Answer is A

Explanation

A. In the context of detecting papilledema, "inspection" refers to using an ophthalmoscope to examine the optic disc for swelling. Papilledema, which is swelling of the optic disc due to increased intracranial pressure, can only be observed through this direct examination of the eye’s interior. This technique is the most appropriate and accurate for confirming papilledema as it allows the nurse to visually inspect the optic disc for signs of swelling or other abnormalities.
B. Percussion involves tapping on the body to assess underlying structures and is commonly used in evaluating lung and abdominal sounds. It is not used for assessing the optic nerve or papilledema. Therefore, percussion is not relevant for confirming the presence of papilledema.
C. Palpation involves feeling the body’s surface to assess for abnormalities such as swelling or
tenderness. It is used for evaluating various parts of the body but does not apply to detecting papilledema. Papilledema involves changes to the optic nerve head, which cannot be assessed through palpation.
D. Auscultation involves listening to internal body sounds using a stethoscope, such as heartbeats, lung sounds, or abdominal sounds. This technique is not used to assess the optic disc or detect papilledema. It is not relevant for the diagnosis of conditions affecting the optic nerve.

A. Firm mass palpated at bottom of left rib cage. B. Rebound tenderness with compression over right upper quadrant. C. Tip of spleen palpable when client is asked to forcefully exhale. D. Pain noted when palpating McBurney's point.

Correct Answer is A

Explanation

A. A firm mass at the bottom of the left rib cage could indicate an enlarged spleen. Splenomegaly can result from various conditions such as infections, liver disease, or blood disorders. This finding is considered abnormal and warrants further evaluation.
B. Rebound tenderness in the right upper quadrant is used to assess for peritoneal irritation, often associated with conditions such as appendicitis. This finding is not specific to the spleen but rather indicates potential issues in the right side of the abdomen, and is not directly related to palpation of the spleen.
C. The spleen is normally not palpable in most people. If the tip of the spleen is palpable during deep palpation or when the client is asked to exhale forcefully, it may indicate mild splenomegaly. While this finding might suggest an abnormality, it is less alarming than a firm, consistently palpable mass.
D. McBurney’s point is located in the right lower quadrant and is used to assess for appendicitis. Pain at McBurney’s point is related to appendiceal inflammation and is not specific to the spleen. This finding does not provide information about the spleen but rather about potential appendiceal pathology.

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When assessing a client's lower extremities, which finding requires immediate intervention by the nurse?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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