Patient Data
Exhibits

When assessing the client's capillary refill status, what would be considered during the procedure? Select all that apply.

Capillary refill is measured in seconds

Capillary refill is the time it takes to return to the client's normal color after releasing pressure

Use your thumbnail and press the nailbed proximal to the injury

Normal should be within 3 seconds or 5 in the older adult

Pressure placed on the nailbed should cause blanching (pale)

Answer and Explanation

Correct Answer : A,B,E

A. Capillary refill is measured in seconds. This is correct. Capillary refill time is a measure of how quickly blood returns to the capillaries after pressure is applied and then released. It is typically measured in seconds.

B. Capillary refill is the time it takes to return to the client's normal color after releasing pressure. This is correct. Capillary refill time measures how quickly the color returns to the nailbed after pressure is applied. This indicates the adequacy of blood flow to the extremity.

C. Use your thumbnail and press the nailbed proximal to the injury. While you should press on the nailbed to assess capillary refill, it is generally recommended to use the pad of your thumb or finger rather than the thumbnail. Additionally, it's important to avoid pressing near the injury site if the area is bruised or painful, as this could distort the assessment.

D. Normal should be within 3 seconds or 5 in the older adult. A normal capillary refill time is generally within 2 seconds for adults. However, it can be up to 3 seconds in some clinical settings. For older adults, the time may be slightly longer, but 5 seconds is usually considered abnormal and may indicate poor perfusion.

E. Pressure placed on the nailbed should cause blanching (pale). This is correct. The application of pressure to the nailbed should cause blanching or paling of the area. The refill time is measured by how quickly the color returns to the nailbed once the pressure is released.

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Correct Answer is A

Explanation

A. Note the client's responses during the initial interview. This allows the nurse to observe the client's natural speech patterns in a conversational context, which is a realistic and comprehensive way to assess speech.

B. Ask the client to complete a common proverb or saying. This approach assesses the client's understanding and familiarity with language but may not comprehensively evaluate speech patterns.

C. Listen while the client reads items listed on the menu. This tests reading ability and articulation but may not reflect the client’s natural speech patterns during conversation.

D. Have the client repeat a phrase containing alliteration. This can help assess speech articulation and clarity but is not comprehensive for evaluating overall speech patterns.

A. Test feet for a positive Babinski reflex. B. Observe color of the feet and toes. C. Assess volume of the pedal pulses. D. Palpate dorsal surface of feet for warmth. E. Measure skin elasticity around the ankles.

Correct Answer is ["B","C","D"]

Explanation

A. Test feet for a positive Babinski reflex. This assesses neurological function but is not directly related to cold feet.

B. Observe color of the feet and toes. This is important as changes in color can indicate poor circulation.

C. Assess volume of the pedal pulses. This is important to assess the adequacy of blood flow to the feet.

D. Palpate dorsal surface of feet for warmth. This directly assesses temperature and potential circulation issues.

E. Measure skin elasticity around the ankles. This assesses hydration status but is less relevant to cold feet.

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Patient Data Exhibits When assessing the client's capillary refill status, what would be considered during the procedure? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Correct Answer is A

Explanation

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.

Correct Answer is ["B","C","D"]

Explanation

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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)?

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Patient Data Exhibits When assessing the client's capillary refill status, what would be considered during the procedure? Select all that apply.

Patient Data
Exhibits

When assessing the client's capillary refill status, what would be considered during the procedure? Select all that apply.