The nurse has completed a peripheral vascular assessment on a client. Which of the following would the nurse document as expected findings?

Capillary refill <5 seconds.

Radial pulses 2+ with regular rate and rhythm bilaterally.

Feet pale and cool to the touch.

Right ankle 1+ edema with no perceptible swelling of the leg.

Answer and Explanation

The Correct Answer is B

A.   A capillary refill of less than 5 seconds is considered normal.
B.   Radial pulses 2+ with regular rate and rhythm bilaterally indicate good peripheral circulation.
C.   Feet that are pale and cool to the touch could indicate decreased perfusion or vascular compromise.
D.   Right ankle 1+ edema may suggest some fluid retention but no perceptible swelling of the leg indicates relatively normal findings in that area.

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Correct Answer is D

Explanation

A. Cranial Nerve XI (Accessory nerve) is not involved in tongue movement; it controls muscles involved in head and shoulder movement.
B. Eye movement and control relate more to Cranial Nerves III, IV, and VI, which control eye muscles.
C. Hearing is primarily assessed by Cranial Nerve VIII (Vestibulocochlear nerve).
D. Cranial Nerve XI innervates the sternocleidomastoid and trapezius muscles, enabling movements like head turning and shoulder shrugging against resistance.

A. Dull throbbing pain that increases with rest. B. Dull ache. C. Sharp pain that increases with movement. D. Deep pain in the wrist.

Correct Answer is C

Explanation

A. Dull throbbing pain increasing with rest might suggest a strain or sprain but not necessarily a fracture.
B. A dull ache could indicate various issues but may not specifically point to a fracture.
C. Sharp pain that worsens with movement is a common indicator of a fracture due to the bones moving against each other.
D. Deep pain in the wrist could signify deep tissue injury but doesn't distinctly indicate a fracture without other signs.

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The nurse has completed a peripheral vascular assessment on a client. Which of the following would the nurse document as expected findings?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is C

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