While completing an admission assessment, the nurse is unable to palpate the client's left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

Use a doppler to assess an audible DP pulse.

Place a mark where DP pulse is auscultated.

Review client's history for vascular disease.

Assess capillary refill distal to the DP pulse.

Answer and Explanation

The Correct Answer is A

A) Use a doppler to assess an audible DP pulse:
Using a doppler to assess an audible DP pulse may provide additional information about the presence or absence of the pulse, but it does not address the underlying cause of the absent pulse. It is important to first investigate potential causes, such as vascular disease, before resorting to additional assessment techniques.

B) Place a mark where DP pulse is auscultated:
Marking the location where the DP pulse is auscultated may assist with future assessments but does not address the underlying reason for the absent pulse. It is essential to determine the cause of the absent pulse before considering further interventions.

C) Review client's history for vascular disease:
Reviewing the client's history for vascular disease is the most important intervention in this scenario. Absence of a DP pulse may indicate peripheral vascular disease or other circulatory issues. Reviewing the client's history for risk factors such as diabetes, hypertension, smoking, or previous vascular problems can provide valuable information to guide further assessment and management.

D) Assess capillary refill distal to the DP pulse:
Assessing capillary refill distal to the DP pulse is important for evaluating peripheral perfusion but may not directly address the underlying cause of the absent pulse. While assessing capillary refill is a valuable assessment, reviewing the client's history for vascular disease takes precedence in determining the cause of the absent DP pulse.

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Correct Answer is A

Explanation

Ecchymosis refers to the discoloration of the skin resulting from bleeding underneath, typically due to bruising. While ecchymosis can occur for various reasons, the use of oral anticoagulants increases the risk of bleeding and bruising. Therefore, the nurse should further assess the client's use of oral anticoagulants to determine if it is contributing to the observed ecchymosis.

B. Works in a day care center:
Working in a day care center may expose the client to various infectious agents, but it is not directly associated with the development of ecchymosis.

C. Recently had dental surgery:
While dental surgery can sometimes result in minor bleeding and bruising, it is less likely to cause widespread ecchymosis unless there are underlying bleeding disorders or complications.

D. Adheres to a gluten-free diet:
Adhering to a gluten-free diet is not directly related to the development of ecchymosis. However, if the client has celiac disease or another condition requiring a gluten-free diet, the nurse should explore the potential for malabsorption or nutritional deficiencies, which could indirectly contribute to bleeding tendencies.

A. Stand directly in front of the client and ask about any hearing loss B. Perform a mental status exam to assess the client's thought processes. C. Begin to orient the client to her surroundings in the hospital room D. Obtain a tuning fork to complete Rinne and Weber tuning fork tests.

Correct Answer is A

Explanation

A) Stand directly in front of the client and ask about any hearing loss:
The client's behavior of ignoring questions and speaking loudly to her son may suggest a hearing impairment. By standing directly in front of the client and asking about any hearing loss, the nurse can assess whether hearing impairment might be contributing to the communication difficulties. This action addresses a potential physiological cause of the observed behavior and allows the nurse to gather essential information to adapt communication strategies effectively.

B) Perform a mental status exam to assess the client's thought processes:
While assessing the client's mental status is important, the observed behavior may be more indicative of a communication issue related to hearing loss rather than a cognitive impairment. Therefore, assessing hearing status would be more appropriate as the initial action.

C) Begin to orient the client to her surroundings in the hospital room:
Orienting the client to her surroundings is important for promoting comfort and reducing confusion, but it may not directly address the observed communication difficulties. Assessing for hearing loss should be prioritized to determine if it contributes to the client's behavior.

D) Obtain a tuning fork to complete Rinne and Weber tuning fork tests:
Conducting Rinne and Weber tuning fork tests may be indicated to assess hearing acuity and differentiate between conductive and sensorineural hearing loss. However, obtaining a tuning fork and performing these tests should occur after gathering initial information about the client's hearing status through direct questioning. Therefore, assessing for hearing loss should be the first action taken by the nurse.

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While completing an admission assessment, the nurse is unable to palpate the client's left dorsalis pedis (DP) pulse. Which intervention is most important for the nurse to implement?

Nursing Test Bank

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Explanation

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