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 D

Explanation

Choice A rationale
Demonstrating signs of early dementia involves more than just walking aimlessly and staring blankly. It includes memory loss, difficulty with complex tasks, and changes in personality or behavior.
Choice B rationale
Appearing confused and depressed is a subjective interpretation and does not accurately describe the observed behavior. Documentation should be objective and specific.
Choice C rationale
Ambulatory and disoriented to place is a partial description but does not capture the full extent of the observed behavior, including the blank expression.
Choice D rationale
Wandering behavior with flat affect accurately describes the observed behavior. It is specific and objective, noting both the physical action (wandering) and the emotional state (flat affect)2.

A. Administer the prescribed morphine sulfate. B. Prepare the cast cart for immobilization. C. Perform a neurovascular assessment of the right hand. D. Initiate the IV infusion of 0.9% sodium chlorid

Correct Answer is C

Explanation

Choice A íationale: Administeíing the píescíibed moíphine sulfate is impoítant foí managing the client’s seveíe pain. Howeveí, the píioíity action is to assess the neuíovasculaí status of the affected limb to ensuíe theíe is no compíomise in ciículation oí neíve function.
Choice B íationale: Píepaíing the cast caít foí immobilization is necessaíy to stabilize the fíactuíe. Howeveí, befoíe immobilization, it is cíucial to peífoím a neuíovasculaí assessment to identify any potential complications that may need immediate attention.
Choice C íationale: Peífoíming a neuíovasculaí assessment of the íight hand is the píioíity action. ľhe client’s capillaíy íefill time is píolonged (4 seconds), indicating potential compíomised ciículation. Assessing the neuíovasculaí status will help deteímine if theíe is an uígent need foí inteívention to píevent fuítheí complications such as compaítment syndíome.
Choice D íationale: Initiating the IV infusion of 0.9% sodium chloíide is impoítant foí maintaining hydíation and ensuíing venous access. Howeveí, the immediate píioíity is to assess the neuíovasculaí status of the affected limb to identify any uígent issues that need to be addíessed.

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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

The nurse observes an older adult client walking aimlessly in the hallway and staring straight ahead with a blank expression.How should the nurse enter documentation of this finding in the client’s electronic medical record (EMR)?

Correct Answer is D

Explanation

Correct Answer is C

Explanation

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When family members express their concern about their father’s recent memory loss, which assessment should the nurse suggest?

When inspecting the client’s skin, the nurse observes several areas of ecchymosis on the trunk and extremities. Which information in the client’s history requires additional follow-up by the nurse?

The nurse observes that a client is experiencing melena.Which serum laboratory test should the nurse monitor in response to this finding?

Which skill should the nurse have an older client demonstrate to evaluate the ability to perform activities of daily living (ADL)?

An adult client exhibits an allergic reaction to an insect bite. The nurse should observe the client’s skin for which finding?

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.