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 A

Explanation

Rationale:
A. Inspect the external ear canals: Muffled hearing, especially if unilateral, may be due to cerumen impaction, swelling, or other obstructions in the external auditory canal. Visual inspection is a quick, non-invasive first step that can help identify mechanical causes of hearing difficulty before pursuing more complex diagnostic tests.

B. Ask client if he has tinnitus: Tinnitus refers to ringing or buzzing in the ears and is often associated with sensorineural hearing loss rather than conductive hearing loss, which is more likely when hearing is muffled. While relevant for a full hearing evaluation, it does not address the immediate symptom of muffled hearing.

C. Determine ability to maintain balance with eyes closed: Balance issues are more related to inner ear dysfunction, particularly involving the vestibular system. Since the client's primary complaint is muffled hearing and not dizziness or balance problems, this assessment is not the most appropriate first step.

D. Differentiate ability to hear high and low pitched sounds: Differentiating pitch perception helps assess for specific types of sensorineural hearing loss. However, before conducting specialized auditory discrimination tests, it is more appropriate to first check for any external, easily correctable issues such as blockage or infection.

A. Numeric pain intensity scale. B. Apical-radial pulse deficit. C. Anteroposterior (AP) chest diameter. D. Body temperature.

Correct Answer is A

Explanation

Rationale:
A. Numeric pain intensity scale: Splinting the chest with a pillow is a common behavioral sign of chest pain or discomfort, often due to surgical incisions, musculoskeletal strain, or cardiac issues. Assessing the client's pain using a numeric scale provides crucial information for guiding pain management and further diagnostic evaluation.

B. Apical-radial pulse deficit: An apical-radial pulse deficit is useful for detecting cardiac arrhythmias, but it is not the immediate priority based on the client's behavior. Addressing the possible cause of splinting, likely pain, should come first before assessing for pulse discrepancies.

C. Anteroposterior (AP) chest diameter: Measuring AP chest diameter helps assess chronic lung conditions such as barrel chest in emphysema. However, this measurement does not address acute signs of pain or discomfort indicated by chest splinting.

D. Body temperature: Checking temperature can help detect infection or fever but is not the most relevant initial assessment when a client is demonstrating behaviors specifically suggestive of chest pain. Pain assessment should take precedence in this context.

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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?

Nursing Test Bank

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Explanation

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