An older male client reports to the nurse that his feet are cold.

Before covering the client’s feet, which assessment(s) should the nurse complete? Select all that apply.

Measure skin elasticity around the ankles.

Assess volume of the pedal pulses.

Palpate dorsal surface of feet for warmth.

Test feet for a positive Babinski reflex.

Observe color of the feet and toes.

Answer and Explanation

Correct Answer : B,C,E

Choice A rationale
Measuring skin elasticity around the ankles is not directly related to assessing the cause of cold feet. It is more relevant for assessing hydration status and skin turgor.
Choice B rationale
Assessing the volume of the pedal pulses is crucial to determine if there is adequate blood flow to the feet.
Choice C rationale
Palpating the dorsal surface of the feet for warmth helps assess the temperature and circulation to the feet.
Choice D rationale
Testing for a positive Babinski reflex is not relevant to assessing cold feet. It is used to assess neurological function.
Choice E rationale
Observing the color of the feet and toes helps assess circulation and potential issues such as cyanosis or pallor.

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Correct Answer is C

Explanation

Choice A rationale
Applying warm blankets to both feet is not the appropriate action when unable to palpate pedal pulses. This action does not address the underlying issue of assessing blood flow.
Choice B rationale
Notifying the healthcare provider is premature without first attempting to locate the pulses using a Doppler ultrasonic stethoscope.
Choice C rationale
Using a Doppler ultrasonic stethoscope is the correct action. This device helps detect and amplify blood flow, allowing the nurse to assess the pulses even if they cannot be palpated manually.
Choice D rationale
Palpating pulse points with legs dependent is not the most effective method to locate non- palpable pulses. Using a Doppler ultrasonic stethoscope is more reliable.

A. Number of blood clots expelled with each stool. B. Unique odor noted with gastrointestinal bleeding. C. Color characteristics of each stool. D. Evidence of internal hemorrhoids.

Correct Answer is C

Explanation

A. Number of blood clots expelled with each stool.Thisis not the most comprehensive approach as it focuses solely on clots without addressing other key aspects, such as stool color or consistency. Clots are also not always present with rectal bleeding.

B. Unique odor noted with gastrointestinal bleeding.While gastrointestinal bleeding, particularly upper GI bleeding, can produce a distinct odor, odor is subjective and not a reliable or standard assessment criterion to document.

C. Color characteristics of each stool.Stool color provides critical information about the source of the bleeding. For example, bright red blood (hematochezia) indicates lower GI bleeding, while black, tarry stools (melena) suggest upper GI bleeding. Documenting stool color helps in identifying the location and nature of the bleeding.

D. Evidence of internal hemorrhoids.While hemorrhoids are a common cause of rectal bleeding, the nurse cannot confirm the presence of internal hemorrhoids without diagnostic tools like anoscopy or sigmoidoscopy. The nurse should focus on documenting observable and measurable findings.

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An older male client reports to the nurse that his feet are cold. Before covering the client’s feet, which assessment(s) should the nurse complete? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While performing a physical assessment, the nurse is unable to palpate the client’s pedal pulses. Which action should the nurse take?

Correct Answer is C

Explanation

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

Correct Answer is C

Explanation

The nurse asks a female client about the proverb “Glass Houses,” and she replies, “It will break the windows.”. Which conclusion should be documented about this client’s response?

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While observing a client’s face, which assessment finding requires immediate intervention by the nurse?

The nurse is examining a female client who states she has no complaints, so has not had a physical examination for over 5 years. The nurse palpates enlarged lymph nodes in the axilla. Which finding is most important for the nurse to describe when reporting to the healthcare provider?

An older male client reports to the nurse that his feet are cold.

Before covering the client’s feet, which assessment(s) should the nurse complete? Select all that apply.