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 B

Explanation

A) White blood cell count (WBC): While an elevated WBC count can indicate infection or inflammation, it is not directly related to melena. Melena, which is black, tarry stool, is usually an indication of gastrointestinal bleeding, specifically from the upper GI tract.

B) Hematocrit: Hematocrit is a measure of the proportion of red blood cells in the blood. Monitoring hematocrit is essential in the context of melena because gastrointestinal bleeding can lead to a decrease in red blood cells, causing anemia. Therefore, tracking hematocrit levels helps assess the severity of blood loss and the client's overall oxygen-carrying capacity.

C) Glucose: Blood glucose levels are not directly related to melena. Monitoring glucose is crucial for managing diabetes and other metabolic disorders but does not provide information about bleeding or anemia.

D) Blood urea nitrogen (BUN): While BUN levels can increase with gastrointestinal bleeding due to the breakdown of blood proteins in the gut, it is not the primary test to monitor for the effects of bleeding. Hematocrit is more directly indicative of blood loss.

A. Closed ended questions. B. Leading questions. C. Detailed questions about a symptom. D. Open ended questioning.

Correct Answer is D

Explanation

A) Closed ended questions:
Closed-ended questions typically elicit short, specific responses and may not provide comprehensive information about the sputum's characteristics.

B) Leading questions:
Leading questions suggest a particular answer and may bias the client's response, preventing the nurse from obtaining an accurate description of the sputum.

C) Detailed questions about a symptom:
While detailed questions can be useful, they may be too specific initially and might not allow the client to freely describe their sputum in their own words.

D) Open ended questioning:
Open-ended questions encourage the client to provide more detailed and descriptive responses, allowing the nurse to gather comprehensive information about the sputum's color, consistency, amount, and other characteristics. This technique is best for obtaining a thorough and accurate description of symptoms.

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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

The nurse observes that a client is experiencing melena. Which serum laboratory test should the nurse monitor in response to this finding?

Correct Answer is B

Explanation

While completing a health assessment for a client being admitted with bilateral pneumonia, the nurse asks the client to describe the sputum. Which communication technique should the nurse use to obtain this information?

Correct Answer is D

Explanation

During assessment of a client's abdomen, the nurse observes that the client's umbilicus is depressed and below the surface of the abdomen. Which action should the nurse take in response to this observation?

When systematically auscultating a client's anterior breath sounds, the nurse should begin by placing the stethoscope over which location?

During the admission assessment, a client admitted with chest pain reports having no breathing problems and no trouble sleeping at night. To obtain further data regarding possible orthopnea, which action should the nurse take?

While auscultating a client's abdomen, the nurse hears a low-pitched blowing sound in the upper midline area. Which is the likely indication of this finding?

The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression. How should the nurse enter documentation of this finding in the client's electronic medical record (EMR)?

The nurse examines a client's right great toe. The joint is red, edematous, and very painful with limited range of motion. The client's serum uric acid levels are elevated. Which action should the nurse tell the client to make?

When evaluating a client's rectal bleeding, which findings should the nurse document?