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

Capillary refill both feet greater than 3 seconds.

Pedal pulses weak and thready.

2+ pitting edema of ankles bilaterally.

Positive Homan's sign bilaterally.

Answer and Explanation

The Correct Answer is C

A. Capillary refill both feet greater than 3 seconds: Delayed capillary refill indicates poor peripheral perfusion but does not directly correlate with swelling.

B. Pedal pulses weak and thready: Weak and thready pedal pulses indicate poor arterial circulation but do not directly confirm swelling.

C. 2+ pitting edema of ankles bilaterally: Pitting edema is a direct indicator of swelling. A 2+ pitting edema specifically confirms the presence of significant fluid accumulation in the tissues of the ankles.

D. Positive Homan's sign bilaterally: A positive Homan's sign can indicate deep vein thrombosis (DVT), which can be associated with swelling but is not a definitive indicator of chronic swelling.

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Correct Answer is B

Explanation

A. Auscultate the lymph node for the presence of a bruit.

Auscultating for a bruit over a lymph node may not be the most immediate or relevant action in this situation. While it could provide additional information about blood flow, it may not necessarily explain the cause of the enlarged lymph node.

B. Ask the client about any localized tenderness at the site.

This is an appropriate action. Localized tenderness at the site of an enlarged lymph node could indicate inflammation or infection. Gathering information about tenderness can help in understanding the possible cause of the lymphadenopathy.

C. Cover the inflamed area and notify the healthcare provider.

This is a reasonable action. Covering the inflamed area can help protect it from further irritation or infection. Notifying the healthcare provider is important because they can assess the lymph node, gather additional history, and determine if further evaluation or treatment is necessary.

D. Record this normal finding in the assessment record.

This option is incorrect. An enlarged, visible lymph node is not considered a normal finding. It could indicate underlying infection, inflammation, or another health issue. Recording it as a normal finding could lead to overlooking potential health concerns.

A. Offer the child bubbles before the stethoscope is placed. B. Allow the child to use a stethoscope on a stuffed animal. C. Place a toy in the child's hands while listening to the breath sounds. D. Have the child blow a cotton ball and have the parent catch it.

Correct Answer is B

Explanation

A. Offer the child bubbles before the stethoscope is placed. Blowing bubbles can help distract the child and make them more relaxed, but it may not be as effective as involving the child directly in the process.

B. Allow the child to use a stethoscope on a stuffed animal. This is an effective approach as it involves the child in the process, making them more comfortable and cooperative. It helps demystify the stethoscope and can reduce fear or anxiety.

C. Place a toy in the child's hands while listening to the breath sounds. Holding a toy can be distracting and help keep the child still, but it does not directly involve the child in the assessment process as effectively as letting them use the stethoscope.

D. Have the child blow a cotton ball and have the parent catch it. Blowing a cotton ball can help with deep breathing, which is useful for lung auscultation. However, it may not ensure the child's cooperation throughout the entire assessment as effectively as option B.

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

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