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.

Nursing Test Bank

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Dimpled area above anus: This can be a sign of a pilonidal cyst, a condition where hair follicles become embedded under the skin.

B. Flap of tissue at sphincter: This could indicate haemorrhoids, swollen veins in the anus and rectum.

C. Hypotonic tone of the anal sphincter: Weak anal sphincter tone can lead to faecal incontinence.

D. Increased pigmentation and coarse skin: This is a normal finding, especially in adults. The perianal area can have a darker colour and thicker skin texture compared to other areas

A. Diminished appetite. B. Lower body mass index (BMI). C. Decreased height. D. 15-pound weight loss.

Correct Answer is C

Explanation

A. Diminished appetite: While this can be a symptom of various conditions, it's not a direct indicator for a bone density screening.

B. Lower body mass index (BMI): A lower BMI can increase the risk of osteoporosis, but it's not a definitive sign requiring immediate bone density screening.

C. Decreased height: Losing height as an adult can be a sign of vertebral fractures caused by osteoporosis. This is a significant finding that warrants a bone density screening to assess bone mineral density.

D. 15-pound weight loss: Sudden or unexplained weight loss can be a concern, but it doesn't directly suggest the need for a bone density test unless accompanied by other risk factors.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While completing an admission assessment for a client with gastrointestinal bleeding, the nurse inspects the perianal area and anus. Which findings indicate a normal appearance of the anus?

Correct Answer is D

Explanation

During a routine health screening of an adult client, the nurse notes several changes that have occurred over the past year. Which change indicates the need for a bone density screening?

Correct Answer is C

Explanation

The nurse is assessing a client who is having pain of the right upper abdominal area. To assess the quality of the client's abdominal pain, which approach should the nurse use?

On the first postpartum day, the nurse examines the breasts of a new mother. Which condition is the nurse most likely to find?

While assessing the skin on an older adult client, the nurse notices hyperpigmented freckles on the client's hands and arms. Which additional nursing assessments are indicated?

The nurse notes an enlarged, visible lymph node on the client's neck. Which action should the nurse take next?

When inspecting the client's skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client's history requires additional follow-up by the nurse?

Which subjective assessment data supports the nurse's conclusion that a client is experiencing orthopnea?

While counting the respirations of an adult client who is bedfast, the nurse observes that the client uses the sternocleidomastoid, trapezius, and abdominal muscles during respirations. Which action should the nurse take in response to this finding?