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 ["A"]

Explanation

A. Abdominal distention can occur due to gas accumulation from undigested lactose.
B. Visible peristalsis is not typically a specific clinical finding associated with lactose intolerance.
C. Hypoactive bowel sounds are not commonly associated with lactose intolerance.
D. Occasional diarrhea is a common symptom due to the inability to digest lactose properly.
E. Flatus or excessive gas production is a common symptom due to the fermentation of undigested lactose by intestinal bacteria.

A. Bone spur B. Crepitation C. Tendonitis D. Fluid in the knee joint

Correct Answer is B

Explanation

A. A bone spur is a bony projection often caused by joint damage, but it does not typically produce audible crunching or grating sounds.
B. Crepitation refers to a crunching, grating, or popping sound or sensation that occurs with movement of a joint. It's often associated with conditions like osteoarthritis.
C. Tendonitis involves inflammation of a tendon and may cause pain or tenderness, but it does not typically produce audible sounds like crepitation.
D. Fluid in the knee joint might cause swelling and limited movement, but it does not usually produce audible crunching or grating sounds.

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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

A nurse is assessing a client who has lactose intolerance. Which of the following will the nurse recognize as clinical findings associated with lactose intolerance? Select all that apply:

Correct Answer is ["A"]

Explanation

A client states, "I can hear a crunching or grating sound when I kneel and have difficulty getting out of bed in the morning because of pain and stiffness." Which of the following should the nurse expect as an assessment finding?

Correct Answer is B

Explanation

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