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
Pupils equal, round, and reactive to light (PERRL) accurately summarizes the findings of the pupillary assessment. It indicates that both pupils are equal in size, round in shape, and react briskly to light, which is a normal finding.
Choice B rationale
Documenting “neurological status intact” is too vague and does not specifically describe the pupillary assessment findings.
Choice C rationale
Pupils equal, round, reactive to light, and accommodation (PERLA) includes an additional assessment of accommodation, which was not mentioned in the scenario.
Choice D rationale
The Glasgow Coma Scale (GCS) of 15 is a general assessment of consciousness and does not specifically describe the pupillary findings.

A. Place the palm of the hand on the chest wall to feel vibrations while the client speaks. B. Looking at the client from the side, observe the size and shape of the chest wall. C. Use a stethoscope to listen to and compare breath sounds anteriorly and posteriorly. D. Use the fingertips to compress tissue over the lungs for evidence of a crackling sensation.

Correct Answer is A

Explanation

Choice A rationale
Placing the palm of the hand on the chest wall to feel vibrations while the client speaks is the correct method to assess tactile fremitus. Increased tactile fremitus can indicate consolidation, as seen in pneumonia.
Choice B rationale
Observing the size and shape of the chest wall does not assess tactile fremitus.
Choice C rationale
Using a stethoscope to listen to and compare breath sounds is not the method for assessing tactile fremitus.
Choice D rationale
Using the fingertips to compress tissue over the lungs for evidence of a crackling sensation is not the correct method for assessing tactile fremitus.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Explanation

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