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

Capillary refill both feet greater than 3 seconds.

Pedal pulses weak and thready.

2+ pitting edema of ankles bilaterally.

Positive Homan's sign bilaterally.

Answer and Explanation

The Correct Answer is C

A. Capillary refill both feet greater than 3 seconds: Delayed capillary refill indicates poor peripheral perfusion but does not directly correlate with swelling.

B. Pedal pulses weak and thready: Weak and thready pedal pulses indicate poor arterial circulation but do not directly confirm swelling.

C. 2+ pitting edema of ankles bilaterally: Pitting edema is a direct indicator of swelling. A 2+ pitting edema specifically confirms the presence of significant fluid accumulation in the tissues of the ankles.

D. Positive Homan's sign bilaterally: A positive Homan's sign can indicate deep vein thrombosis (DVT), which can be associated with swelling but is not a definitive indicator of chronic swelling.

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Correct Answer is D

Explanation

A. Takes a first step alone: This is typically achieved closer to 12 months.

B. Sits alone unsupported: Some 8-month-olds might achieve this, but pulling to sit is a more consistent milestone at this age.

C. Can feed self finger food: While some babies might explore finger foods at 8 months, independent feeding is usually a skill developed later.

D. Pulls self to sitting position: This demonstrates developing upper body strength and coordination, commonly seen around 8-9 months.

A. Observe for eye opening to a painful stimulus. B. Ask the client to open his eyes. C. Notify the healthcare provider. D. Check the pupillary response to light.

Correct Answer is B

Explanation

A. Observe for eye opening to a painful stimulus: Using a painful stimulus is part of the Glasgow Coma Scale (GCS) assessment for level of consciousness, providing a systematic way to determine the client's response level. This step should follow if the client does not respond to verbal commands.

B. Ask the client to open his eyes: This is a less invasive step that should be attempted first before applying a painful stimulus. It can provide immediate information about the client's level of consciousness and ability to follow commands.

C. Notify the healthcare provider: Notifying the healthcare provider is essential if the client's condition is critical or worsening. However, it should follow after initial assessment steps have been taken to determine the immediate status.

D. Check the pupillary response to light: Checking pupillary response is important for neurological assessment but does not directly address the need to evaluate the client's response to stimuli, which is critical for assessing consciousness levels.

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

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