Which assessment finding supports the client statement, “My feet swell all the time?”

Positive Homan’s sign bilaterally.

2+ pitting edema of ankles bilaterally.

Pedal pulses weak and thready.

Capillary refill in both feet greater than 3 seconds.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Positive Homan’s sign bilaterally indicates deep vein thrombosis (DVT) but does not directly correlate with swelling.
Choice B rationale
2+ pitting edema of ankles bilaterally is a direct indication of swelling and supports the client’s statement about their feet swelling all the time.
Choice C rationale
Pedal pulses weak and thready indicate poor arterial circulation but do not directly confirm swelling.
Choice D rationale
Capillary refill in both feet greater than 3 seconds indicates poor peripheral perfusion but does not directly correlate with swelling.

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Correct Answer is A

Explanation

Choice A rationale
Generalized lumpiness of both breasts with no discrete masses and no nipple discharge is a common finding, especially before menstrual periods. Assuring the client that her breasts are normal and advising annual evaluations is appropriate.
Choice B rationale
Requesting a return visit after her menstrual period for a breast exam re-check is unnecessary if the findings are consistent with normal premenstrual changes.
Choice C rationale
Explaining to the client that an ultrasound of the breast will likely be necessary is not warranted based on the current findings.
Choice D rationale
Suggesting that the client schedule a mammogram after her next menstrual period is not necessary for a young adolescent with normal premenstrual breast changes.

A. Painful symptoms alleviated by warmth. B. Cool, pale skin below the knees. C. Decreased pain when legs are elevated. D. Deep, continuous pain in the calf muscles.

Correct Answer is C

Explanation

Choice A rationale
Painful symptoms alleviated by warmth are more indicative of conditions such as arthritis or muscle strain rather than venous insufficiency.
Choice B rationale
Cool, pale skin below the knees is more indicative of arterial insufficiency rather than venous insufficiency.
Choice C rationale
Decreased pain when legs are elevated is a common symptom of venous insufficiency. Elevating the legs helps reduce venous pressure and alleviate symptoms such as swelling and aching.
Choice D rationale
Deep, continuous pain in the calf muscles is more indicative of conditions such as deep vein thrombosis (DVT) rather than venous insufficiency.

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Which assessment finding supports the client statement, “My feet swell all the time?”

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adolescent female client comes to the clinic troubled by breast tenderness before her menstrual periods. On examination, the nurse notes generalized lumpiness of both breasts with no discrete masses and no nipple discharge. Which action should the nurse take?

Correct Answer is A

Explanation

While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

Correct Answer is C

Explanation

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