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.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is A

Explanation

Choice A rationale
Observing pupil size when focusing on a near object and then a far object assesses the accommodation reflex. This reflex involves the pupils constricting when focusing on a near object and dilating when focusing on a far object. This response is mediated by the parasympathetic nervous system and is a normal physiological reaction to changes in focal distance.
Choice B rationale
Determining if dilation of the pupils occurs when the room is darkened assesses the pupillary light reflex, not accommodation. The pupillary light reflex involves the pupils dilating in low light conditions to allow more light to enter the eye, which is controlled by the sympathetic nervous system.
Choice C rationale
Noting the speed of pupil constriction when a penlight is shined into the eye assesses the direct and consensual light reflexes. This test evaluates the function of the optic and oculomotor nerves and is not related to the accommodation reflex.
Choice D rationale
Comparing the shape of each of the pupils bilaterally with normal room light assesses for anisocoria or differences in pupil size, which can indicate neurological issues. This assessment does not evaluate the accommodation reflex.

A. Ask the client to complete a common proverb or saying. B. Have the client repeat a phrase containing alliteration. C. Note the client’s responses during the initial interview. D. Listen while the client reads items listed on the menu.

Correct Answer is C

Explanation

Choice A rationale
Asking the client to complete a common proverb or saying can provide some insight into cognitive function and language skills, but it may not comprehensively assess speech patterns. This method may also be influenced by the client’s familiarity with specific proverbs.
Choice B rationale
Having the client repeat a phrase containing alliteration can assess specific aspects of speech, such as articulation and fluency. However, it may not provide a holistic assessment of speech patterns and may not be suitable for all clients.
Choice C rationale
Noting the client’s responses during the initial interview allows the nurse to observe the client’s spontaneous speech patterns, including articulation, fluency, rate, and coherence, during the natural flow of conversation. This approach provides a comprehensive assessment of speech abilities in various contexts.
Choice D rationale
Listening while the client reads items listed on the menu can assess reading ability and pronunciation, but it may not fully capture speech patterns in spontaneous conversation or communication. Additionally, it may not be relevant to clients who may have difficulty reading or have limited literacy skills.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

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

To assess a client’s pupillary reaction to accommodation, which action should the nurse take?

Correct Answer is A

Explanation

During an admission assessment, which approach should the nurse use to assess a client’s speech patterns?

Correct Answer is C

Explanation

The nurse completes palpation of the thoracic region on an adult client. Which finding is considered normal for this client?

While percussing the borders of the heart, the nurse picks up an area of dullness beginning at the 5th left intercostal space and moving upward to the 2nd left intercostal space at the sternal border. What do these findings indicate?

While obtaining a client’s health history related to smoking cigarettes, the nurse plans to determine the client’s smoking pack years. What information should the nurse obtain for this calculation? Select all that apply.

The nurse is examining an older female client and suspects that she has a dysfunction in her hip region. Which procedure should the nurse perform to further assess for hip dysfunction?

While auscultating a client’s breath sounds, the nurse hears vesicular sounds in the bases of both lungs posteriorly. Which action should the nurse take in response to this finding?

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

Heart sounds are loudest for S1 at the ______ and S2 at the _____.

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.