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.
Test feet for a positive Babinski reflex.
Observe color of the feet and toes.
Measure skin elasticity around the ankles.
Assess volume of the pedal pulses.
Palpate dorsal surface of feet for warmth.
Correct Answer : B,D,E
Choice A Reason:
Testing feet for a positive Babinski reflex is wrong. The Babinski reflex is a neurological test that assesses upper motor neuron function, particularly in the lower extremities. However, it is not relevant to assessing cold feet, and testing for the Babinski reflex would not provide useful information in this situation.
Choice B Reason:
Observing color of the feet and toes is wright. Observing the color of the feet and toes can provide important information about circulation. Pallor, cyanosis, or mottling may indicate inadequate blood flow or perfusion to the extremities, which could contribute to cold feet.
Choice C Reason:
Measuring skin elasticity around the ankles is wrong. Skin elasticity assessment is more relevant for evaluating hydration status or tissue turgor. While it may be useful in certain contexts, it is not directly related to assessing cold feet and peripheral circulation. Therefore, it is not necessary before covering the client's feet in this scenario.
Choice D Reason:
Assessing volume of the pedal pulses is wright. Assessing the volume of the pedal pulses (such as dorsalis pedis and posterior tibial pulses) provides information about peripheral vascular status. Weak or absent pulses may indicate compromised circulation, contributing to cold feet.
Choice E Reason:
Palpating dorsal surface of feet for warmth is wright. palpating the dorsal surface of the feet for warmth helps assess peripheral perfusion. Coolness to touch may indicate decreased blood flow to the extremities, while warmth suggests adequate circulation.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A Reason:
During an abdominal assessment, the client's pain and abrupt cessation of inhalation during deep palpation, especially when accompanied by a high fever (103° F or 39.4° C), is indicative of potential peritonitis or an acute abdomen condition (e.g., appendicitis).Keeping the client NPO (nothing by mouth) is crucial to prepare them for potential emergency surgical intervention. Eating or drinking could complicate anesthesia and the surgical procedure.
Choice B Reason:
Electrocardiogram is incorrect. An electrocardiogram (ECG) may be indicated to assess cardiac function and rule out cardiac causes of chest pain or discomfort, particularly if there are associated symptoms such as shortness of breath or palpitations. However, in this scenario, the client's symptoms (abdominal pain, sudden cessation of inhalation during deep palpation, and elevated temperature) suggest a more immediate concern related to the abdominal condition rather than a primary cardiac issue.
Choice C Reason:
This is important for overall patient monitoring, but it is not the immediate priority for managing acute abdominal pain with suspected peritonitis.
Choice D Reason:
Complete bed rest is incorrect. Complete bed rest may be recommended in some cases of acute illness or injury to promote healing and prevent further exacerbation of symptoms. However, in this scenario, the client's symptoms suggest a potentially serious abdominal condition requiring further assessment and intervention beyond bed rest alone.
Correct Answer is C
Explanation
Choice A Reason:
History of a fractured patella is incorrect. While a history of a fractured patella may lead to some degree of crepitation in the knee joint, especially if there was damage to the articular surfaces during the injury, it is less likely to cause widespread crepitation with joint movement. Crepitation associated with a fractured patella would typically be localized to the site of injury rather than throughout the joint.
Choice B Reason:
Knee arthroplasty surgery is incorrect. Knee arthroplasty surgery involves the replacement of a damaged knee joint with an artificial prosthesis. While crepitation can occur in some cases following knee arthroplasty, it is less likely to be the cause of crepitation observed in this scenario, especially if the client's knee arthroplasty was successful and without complications.
Choice C Reason:
Degenerative disease is correct. Degenerative disease of the knee joint, such as osteoarthritis, is a common cause of crepitation during joint movement. Osteoarthritis is characterized by the breakdown of cartilage in the joints, leading to friction between bones and resulting in crepitus. This condition is often associated with aging, repetitive stress on the joints, or underlying joint abnormalities.
Choice D Reason:
Needle aspiration of the synovial space is incorrect. Needle aspiration of the synovial space is a procedure performed to remove excess fluid or to obtain a sample of synovial fluid for diagnostic purposes. While this procedure may be performed for various reasons, it is not directly associated with crepitation in the knee joint.
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