A nurse is caring for a client who has musculoskeletal injuries to the left lower extremity. Which of the following assessments should the nurse perform to evaluate the neurovascular status of the client's extremity?
Check skin temperature distal to the injury with the dorsum of the hand.
Press the heel of the foot to determine capillary refill.
Monitor sensation by palpating the pad of the great toe with a blunt needle.
Compare the color of the skin proximal to the injury with the other extremity.
The Correct Answer is A
A. Check skin temperature distal to the injury with the dorsum of the hand.: Assessing skin temperature distal to the injury is an important part of evaluating neurovascular status. It helps to identify any changes in circulation or potential complications like ischemia. The dorsum of the hand is commonly used as it provides a good comparison to the temperature of the affected extremity.
B. Press the heel of the foot to determine capillary refill.: While capillary refill is an important assessment, it is usually measured by pressing the nail beds or pads of the fingers and toes, not by pressing the heel. This method does not provide a reliable indication of neurovascular status.
C. Monitor sensation by palpating the pad of the great toe with a blunt needle.: While assessing sensation is important, it is typically done using a light touch or pinprick, rather than palpating with a blunt needle. The use of a needle is not standard practice for this type of assessment.
D. Compare the color of the skin proximal to the injury with the other extremity.: Comparing the skin color distal to the injury with the unaffected extremity is more relevant for evaluating neurovascular status. Proximal comparison is less effective in assessing circulation and potential issues related to the injury.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A) Drink cold beverages to increase peristalsis: While hydration is important for overall health, drinking cold beverages specifically is not a well-supported method for increasing peristalsis. The key to avoiding constipation is adequate fluid intake, but it doesn't need to be cold.
B) Increase daily water intake: Increasing daily water intake is a fundamental and effective strategy to prevent constipation. Adequate hydration helps soften the stool, making it easier to pass and promoting regular bowel movements.
C) Take a daily laxative to soften stools: Relying on a daily laxative is not recommended for long-term management of constipation as it can lead to dependence and disrupt normal bowel function. Dietary and lifestyle changes are preferred for preventing constipation.
D) Eat a low-residue diet: A low-residue diet, which is low in fiber and roughage, is typically used for specific medical conditions and may contribute to constipation rather than prevent it. To avoid constipation, a high-fiber diet is usually recommended to promote healthy bowel movements.
Correct Answer is C
Explanation
A) Asking the client how she feels about her understanding of diabetes can provide some insight into her confidence and perceived knowledge. However, it does not objectively measure her actual understanding or ability to apply diabetes management information.
B) Asking the client how often she reads food labels assesses a specific behavior related to diabetes management but does not fully evaluate the client's overall health literacy. The frequency of reading food labels may indicate some level of engagement, but it does not necessarily reflect comprehensive understanding or effective diabetes self-management.
C) Requesting the client to explain what she read from a brief handout about diabetes management provides a direct assessment of her comprehension and retention of diabetes management information. This approach effectively measures her ability to understand and apply critical health information, which is a core component of health literacy.
D) Inquiring about the timing of her last HbA1c test assesses adherence to diabetes monitoring but does not gauge the client's understanding of diabetes management. While important, this question does not provide a clear picture of her health literacy or ability to manage her condition effectively.
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