While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

Deep, continuous pain in the calf muscles.

Painful symptoms alleviated by warmth.

Cool, pale skin below the knees.

Decreased pain when legs are elevated.

Answer and Explanation

The Correct Answer is D

A. Deep, continuous pain in the calf muscles:
Deep, continuous pain in the calf muscles is more indicative of conditions such as deep vein thrombosis (DVT) rather than venous insufficiency.

B. Painful symptoms alleviated by warmth:
Painful symptoms alleviated by warmth are more characteristic of arterial insufficiency, such as in peripheral arterial disease (PAD), rather than venous insufficiency.

C. Cool, pale skin below the knees:
Cool, pale skin below the knees is also more suggestive of arterial insufficiency rather than venous insufficiency. Arterial insufficiency often presents with decreased blood flow to the extremities, resulting in coolness and pallor.

D. Decreased pain when legs are elevated:
This is the correct answer. Venous insufficiency typically results in symptoms such as aching, tired legs, and swelling, which worsen with prolonged standing but improve with leg elevation. This is due to the reduction in venous pressure when the legs are elevated, which helps alleviate symptoms associated with venous congestion and stasis.

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Correct Answer is C

Explanation

A) Ask the client to complete a common proverb or saying:
While completing a common proverb or saying can provide some insight into speech patterns, it may not offer a comprehensive assessment of the client's speech abilities. Additionally, the client's familiarity with specific proverbs or sayings could influence their performance.

B) Have the client repeat a phrase containing alliteration:
Having the client repeat a phrase containing alliteration can assess specific aspects of speech, such as articulation and fluency. However, it may not provide a holistic assessment of speech patterns and may not be suitable for all clients.

C) Note the client's responses during the initial interview:
This approach allows the nurse to observe the client's spontaneous speech patterns, including articulation, fluency, rate, and coherence, during the natural flow of conversation. It provides a comprehensive assessment of speech abilities in various contexts.

D) Listen while the client reads items listed on the menu:
While listening to the client read items on a menu can assess reading ability and pronunciation, it may not fully capture speech patterns in spontaneous conversation or communication. Additionally, it may not be relevant to clients who may have difficulty reading or have limited literacy skills.

A. Notify the healthcare provider of the rebound tenderness. B. Obtain a prescription to catheterize the client's bladder. C. Offer to administer a laxative prescribed for PRN use. D. Instruct the client in distraction and relaxation techniques.

Correct Answer is A

Explanation

A) Notify the healthcare provider of the rebound tenderness:
Rebound tenderness, also known as Blumberg's sign, is a clinical sign that suggests peritoneal irritation, which can be indicative of underlying pathology such as peritonitis. Reporting rebound tenderness to the healthcare provider is crucial for further evaluation and management of the client's condition.

B) Obtain a prescription to catheterize the client's bladder:
While urinary retention can present with lower abdominal discomfort, the scenario described does not specifically suggest urinary retention. Catheterization should be considered based on additional assessments and indications related to urinary symptoms, not solely based on the client's report of pain upon release of abdominal pressure.

C) Offer to administer a laxative prescribed for PRN use:
Administering a laxative would not be appropriate based solely on the client's report of pain upon release of abdominal pressure. Laxatives are indicated for constipation, which may cause abdominal discomfort, but they would not address rebound tenderness or the underlying cause of the client's pain.

D) Instruct the client in distraction and relaxation techniques:
While distraction and relaxation techniques can be helpful for managing pain, they would not address the underlying cause of rebound tenderness. Reporting rebound tenderness to the healthcare provider is necessary for further evaluation and appropriate management.

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While assessing the legs of an adult client, the nurse observes leathery-looking skin. The client reports aching, tired legs that swell if standing for long periods of time. To screen for venous insufficiency, the nurse should ask the client if they have experienced which subjective finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an admission assessment, which approach should the nurse use to assess a client's speech patterns?

Correct Answer is C

Explanation

The nurse applies pressure over an area of the lower abdomen where the client reports pain. The client denies pain upon palpation, but reports pain when the pressure is released. Which action should the nurse implement?

Correct Answer is A

Explanation

In assessing a client's neck, the nurse hears a blowing swish when auscultating the area over the left carotid artery, but hears no sound over the right carotid artery. How should the nurse document this finding?

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