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. Listen for abnormal sounds. Before identifying abnormal sounds, it's essential to first establish a baseline by identifying the normal heart sounds (S1 and S2).

B. Identify S1 and S2 heart sounds. This is the correct first step in a systematic assessment of heart sounds. S1 ("lub") corresponds to the closure of the atrioventricular valves (mitral and tricuspid), while S2 ("dub") corresponds to the closure of the semilunar valves (aortic and pulmonic).

C. Move the stethoscope to the apical site. While the apical site is important for auscultating specific heart sounds, it's best to first identify S1 and S2 at the traditional auscultatory areas (aortic, pulmonic, tricuspid, and mitral).

D. Change to the bell of the stethoscope. The bell of the stethoscope is used to listen for lower-pitched sounds, but it's not typically used for identifying S1 and S2 heart sounds, which are higher-pitched.

Correct Answer is ["9"]

Explanation

To determine the Apgar score for the newborn infant, we assess five parameters: heart rate, respiratory effort, muscle tone, reflex irritability, and color. Each parameter is scored from 0 to 2, with 2 being the highest score. Let's evaluate each parameter:

Heart rate: 150 beats/minute --> Score of 2.
Respiratory effort: Vigorous cry present --> Score of 2.
Muscle tone: Good muscle tone with total flexion --> Score of 2.
Reflex irritability: Quick reflex irritability noted --> Score of 2.
Color: Dusky and cyanotic skin color --> Score of 1.

Now, we sum up the scores: 2+2+2+2+1=92+2+2+2+1=9

Therefore, the Apgar score for this infant is 9.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse prepares to begin a systematic assessment of a client's heart sounds. Upon positioning the stethoscope as seen in the picture, which should the nurse do first?

Correct Answer is B

Explanation

Correct Answer is ["9"]

Explanation

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