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. Determine degree of skin elasticity: While decreased skin elasticity can be a sign of aging, it doesn't directly assess muscle tone or strength.

B. Measure muscle strength: This is the most appropriate next step to confirm the nurse's initial suspicion of weak muscles. Techniques like manual muscle testing can assess muscle strength.

C. Inspect appearance of the spine: Spinal issues can affect movement and coordination, but they wouldn't necessarily explain soft and boggy muscles in one arm.

D. Note 24-hour fluid intake and output: This might be relevant for overall health assessment but doesn't directly assess muscle tone or strength.

A. "I cough a lot at night and it keeps me up half the night." B. "I sleep on three pillows at night." C. " have multiple attacks of wheezing almost daily." D. "It doesn't take much activity before I'm out of breath."

Correct Answer is B

Explanation

A. "I cough a lot at night and it keeps me up half the night." Night-time coughing can be associated with various conditions, including asthma, GERD, or postnasal drip, but it is not specifically indicative of orthopnoea.

B. "I sleep on three pillows at night." This supports orthopnoea, which is difficulty breathing when lying flat. Clients with orthopnoea often use multiple pillows to elevate their upper body to alleviate shortness of breath.

C. "I have multiple attacks of wheezing almost daily." Frequent wheezing is more indicative of asthma or other obstructive airway diseases, not orthopnoea.

D. "It doesn't take much activity before I'm out of breath." This describes dyspnoea on exertion, which is different from orthopnoea, as it refers to difficulty breathing during physical activity rather than when lying down.

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

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