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

2+ pitting edema of ankles bilaterally.

Capillary refill both feet greater than 3 seconds.

Pedal pulses weak and thready.

Positive Homan's sign bilaterally.

Answer and Explanation

The Correct Answer is A

A. 2+ pitting edema of ankles bilaterally. This is the best choice because it directly indicates fluid retention and swelling in the feet.

B. Capillary refill both feet greater than 3 seconds. Delayed capillary refill suggests poor circulation but does not directly confirm swelling.

C. Pedal pulses weak and thready. Weak pulses indicate poor circulation but do not confirm swelling.

D. Positive Homan's sign bilaterally. Positive Homan's sign can indicate deep vein thrombosis but does not directly relate to chronic swelling.

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Correct Answer is D

Explanation

A. Obtain a drug urine screen to verify the legitimacy of the client's stated history. This may be necessary but is not the initial approach for obtaining a health history.

B. Use the term illegal or illicit to describe street drugs. Using stigmatizing terms may make the client uncomfortable and less likely to disclose information.

C. Allow the client to decline answering social questions. The nurse should encourage open communication, but also respect the client's right to privacy.

D. Ask specifically about alcohol, marijuana, cocaine, heroin, and amounts. This is the correct approach. Specific questions about substances and quantities help obtain accurate information.

A. Use a warmed bell of the stethoscope and place it lightly over the four quads B. Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent C. Turn the suction off while auscultating D. Palpate the abdomen before auscultating E. Place the stethoscope in the ears with the earpieces pointing towards the ears

Correct Answer is ["A","C","E"]

Explanation

A. Use a warmed bell of the stethoscope and place it lightly over the four quadrants. Using a warmed stethoscope bell helps ensure that the stethoscope is at a comfortable temperature for the patient. However, the diaphragm of the stethoscope is typically used for bowel sounds, not the bell. Placing the stethoscope lightly over all four quadrants ensures that you are listening to all areas of the abdomen.

B. Auscultate at least 5 minutes of continuous listening before determining that bowel sounds are absent. This is not necessary for most clinical situations. If bowel sounds are not heard within 1-2 minutes, you may document them as absent. Listening for a full 5 minutes is typically reserved for more specific assessments, such as suspected bowel obstruction.

C. Turn the suction off while auscultating. Suction from a nasogastric tube can cause noise that may interfere with the assessment of bowel sounds. Turning off the suction ensures that you can hear the actual bowel sounds without interference.

D. Palpate the abdomen before auscultating. Palpation should be done after auscultation to avoid stimulating bowel sounds, which can affect the accuracy of your assessment. Palpating before auscultation may alter the natural bowel sounds and provide misleading results.

E. Place the stethoscope in the ears with the earpieces pointing towards the ears. The earpieces of the stethoscope should point towards the ears to ensure proper acoustics and clear sound transmission.

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

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Naxlex Comprehensive Predictor Exams

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