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.

Palpate dorsal surface of feet for warmth.

Test feet for a positive Babinski reflex.

Measure skin elasticity around the ankles.

Assess volume of the pedal pulses.

Observe color of the feet and toes.

Answer and Explanation

Correct Answer : A,D,E

A) Palpate dorsal surface of feet for warmth:
Assessing the temperature of the dorsal surface of the feet helps determine peripheral circulation and can indicate whether the feet are indeed cold. Cold feet may suggest poor peripheral perfusion or circulation issues, which require further assessment.

B) Test feet for a positive Babinski reflex:
The Babinski reflex is typically tested to assess upper motor neuron dysfunction and is not directly relevant to evaluating the complaint of cold feet.

C) Measure skin elasticity around the ankles:
Measuring skin elasticity around the ankles may be relevant for assessing skin turgor and hydration status but is not specifically related to evaluating the client's complaint of cold feet.

D) Assess volume of the pedal pulses:
Assessing the volume of pedal pulses provides information about peripheral perfusion and circulation. Diminished or absent pedal pulses may indicate peripheral vascular disease or other circulatory issues contributing to cold feet. It's essential to evaluate the strength and symmetry of pedal pulses to determine peripheral vascular status.

E) Observe color of the feet and toes:
While observing the color of the feet and toes is important for assessing circulation and perfusion, it is not specific to evaluating the client's complaint of cold feet. However, color changes, such as pallor or cyanosis, may provide additional information about peripheral circulation and require further assessment.

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Correct Answer is A

Explanation

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.

A. Hypogastric region. B. Epigastric region. C. Umbilical region. D. Hypochondriac region.

Correct Answer is B

Explanation

A) Hypogastric region:
The hypogastric region, also known as the suprapubic region, is located below the umbilical region and above the pubic area. Pain in the hypogastric region would be lower in the abdomen than described.

B) Epigastric region:
The epigastric region is located in the upper central part of the abdomen, just below the xiphoid process. Pain localized in the middle section of the abdomen below the xiphoid process is described as occurring in the epigastric region.

C) Umbilical region:
The umbilical region is located around the navel (belly button). Pain in this area would be centered around the umbilicus and not higher up near the xiphoid process.

D) Hypochondriac region:
The hypochondriac regions are located on either side of the epigastric region and below the ribcage. Pain in the hypochondriac region would be more lateral and not centrally located below the xiphoid process.

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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.

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Naxlex Comprehensive Predictor Exams

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