Which assessment finding supports the client statement, “My feet swell all the time?”

Positive Homan’s sign bilaterally.

2+ pitting edema of ankles bilaterally.

Pedal pulses weak and thready.

Capillary refill in both feet greater than 3 seconds.

Answer and Explanation

The Correct Answer is B

Choice A rationale
Positive Homan’s sign bilaterally indicates deep vein thrombosis (DVT) but does not directly correlate with swelling.
Choice B rationale
2+ pitting edema of ankles bilaterally is a direct indication of swelling and supports the client’s statement about their feet swelling all the time.
Choice C rationale
Pedal pulses weak and thready indicate poor arterial circulation but do not directly confirm swelling.
Choice D rationale
Capillary refill in both feet greater than 3 seconds indicates poor peripheral perfusion but does not directly correlate with swelling.

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Correct Answer is B

Explanation

Choice A rationale
Impaired memory would be indicated by difficulty recalling recent events or information, not by an inability to understand or interpret a proverb.
Choice B rationale
Impaired thinking is suggested by the client’s literal interpretation of the proverb “Glass Houses.”. This indicates difficulty with abstract thinking and understanding figurative language, which can be a sign of cognitive impairment.
Choice C rationale
Normal mental status for age would be indicated by the ability to understand and interpret common proverbs and idioms appropriately. The client’s response does not align with this.
Choice D rationale
Impaired concentration would be indicated by difficulty focusing on tasks or maintaining attention, not by a literal interpretation of a proverb.

A. Observe pupil size when focusing on a near object and then a far object. B. Determine if dilation of the pupils occurs when the room is darkened. C. Note the speed of pupil constriction when a penlight is shined into the eye. D. Compare the shape of each of the pupils bilaterally with normal room light.

Correct Answer is A

Explanation

Choice A rationale
Observing pupil size when focusing on a near object and then a far object assesses the accommodation reflex. This reflex involves the pupils constricting when focusing on a near object and dilating when focusing on a far object. This response is mediated by the parasympathetic nervous system and is a normal physiological reaction to changes in focal distance.
Choice B rationale
Determining if dilation of the pupils occurs when the room is darkened assesses the pupillary light reflex, not accommodation. The pupillary light reflex involves the pupils dilating in low light conditions to allow more light to enter the eye, which is controlled by the sympathetic nervous system.
Choice C rationale
Noting the speed of pupil constriction when a penlight is shined into the eye assesses the direct and consensual light reflexes. This test evaluates the function of the optic and oculomotor nerves and is not related to the accommodation reflex.
Choice D rationale
Comparing the shape of each of the pupils bilaterally with normal room light assesses for anisocoria or differences in pupil size, which can indicate neurological issues. This assessment does not evaluate the accommodation reflex.

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Which assessment finding supports the client statement, “My feet swell all the time?”

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse asks a female client about the proverb “Glass Houses,” and she replies, “It will break the windows.”. Which conclusion should be documented about this client’s response?

Correct Answer is B

Explanation

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Correct Answer is A

Explanation

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