While completing a health assessment for a client with peripheral vascular disease (PVD), which assessment technique is most important for the nurse to implement?

Document thickened toe nails.

Palpate and document quality of distal pulses.

Measure ankle-brachial index (ABI).

Measure and record dependent ankle edema.

Answer and Explanation

The Correct Answer is B

Rationale:
A. Document thickened toe nails: Thickened toenails can be a sign of poor circulation associated with PVD, but documenting this alone does not provide critical information about current perfusion status. While important, it is less urgent compared to assessing the functionality of blood flow through distal pulses.

B. Palpate and document quality of distal pulses: Palpating distal pulses, such as dorsalis pedis and posterior tibial, is crucial to assess arterial blood flow to the extremities. In clients with PVD, weak or absent pulses can indicate worsening ischemia, making this assessment vital for early intervention and monitoring disease progression.

C. Measure ankle-brachial index (ABI): ABI is a non-invasive diagnostic test that measures the ratio of ankle to arm blood pressure to confirm PVD severity. It is a key diagnostic tool for PVD and provides objective data on the severity of arterial disease. However, in the context of a routine health assessment, palpating distal pulses offers immediate, albeit subjective, information about perfusion. While ABI is important, pulse assessment is often the initial and most readily available technique during a physical exam.

D. Measure and record dependent ankle edema: Dependent edema is more indicative of venous insufficiency rather than arterial PVD. Although documenting edema can assist in the overall vascular assessment, it does not directly evaluate arterial perfusion, which is the primary concern in PVD clients.

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Correct Answer is B

Explanation

Rationale:
A. Amount and type of caffeinated drinks before bedtime: Caffeine intake can definitely impact sleep quality, but assessing specific contributors like caffeine is a secondary step. First, the nurse must gather broader information about overall sleep habits to identify where disturbances occur.

B. Usual bed time and time of awakenings: Establishing the client’s typical sleep and wake times is the foundation for evaluating a sleep pattern disturbance. It helps determine whether the issue lies with sleep onset, maintenance, early awakening, or overall duration, guiding the development of a targeted and effective care plan.

C. History of seasonal allergies and nasal congestion: Allergies and congestion can disrupt sleep by causing breathing difficulties, but they are secondary considerations. These should be explored after first understanding the client's general sleep routine and identifying primary sleep concerns.

D. Urinary frequency and episodes of nocturia: Nocturia can significantly disrupt sleep, especially in older adults. However, like other specific contributors, it should be assessed after the overall sleep pattern is reviewed to ensure a comprehensive understanding of the client's sleep issues.

A. Percussion. B. Palpation. C. Auscultation. D. Observation.

Correct Answer is D

Explanation

Rationale:
A. Percussion: Percussion is used to assess underlying lung structures for air, fluid, or consolidation by evaluating sound changes. It is not the correct technique for assessing the physical shape or chest dimensions like the AP diameter.

B. Palpation: Palpation helps detect areas of tenderness, masses, or chest wall movement but does not accurately measure or evaluate the visual proportion of the AP to transverse chest diameter.

C. Auscultation: Auscultation is performed to assess lung sounds, such as crackles, wheezes, or diminished breath sounds. It does not provide information about the external shape or contour of the chest.

D. Observation: Observation is the correct method for assessing AP chest diameter. By visually inspecting the client from the side, the nurse can determine whether the chest is normally proportioned (approximately 1:2 AP to transverse ratio) or if there are abnormalities such as barrel chest, which can indicate chronic lung disease.

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While completing a health assessment for a client with peripheral vascular disease (PVD), which assessment technique is most important for the nurse to implement?

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