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

2+ pitting edema of ankles bilaterally.

Capillary refill both feet greater than 3 seconds.

Pedal pulses weak and thready.

Positive Homan's sign bilaterally.

Answer and Explanation

The Correct Answer is A

A. 2+ pitting edema of ankles bilaterally. This is the best choice because it directly indicates fluid retention and swelling in the feet.

B. Capillary refill both feet greater than 3 seconds. Delayed capillary refill suggests poor circulation but does not directly confirm swelling.

C. Pedal pulses weak and thready. Weak pulses indicate poor circulation but do not confirm swelling.

D. Positive Homan's sign bilaterally. Positive Homan's sign can indicate deep vein thrombosis but does not directly relate to chronic swelling.

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Correct Answer is B

Explanation

A. Measure the blood pressure when the client is lying and standing. Measuring blood pressure in different positions assesses for orthostatic hypotension, not orthopnea.

B. Ask the client how many pillows are used to sleep on at night. This is the best choice because orthopnea is often managed by sleeping with multiple pillows to relieve difficulty breathing when lying flat.

C. Observe for jugular vein distention while the client is flat in bed. Jugular vein distention can indicate heart failure but does not directly assess orthopnea.

D. Auscultate breath sounds while the client is supine. This assesses lung sounds but does not directly address the client's sleep position or orthopnea.

A. Reading a short paragraph. B. Telephoning a family member. C. Opening a bar soap package. D. Sorting a collection of socks.

Correct Answer is C

Explanation

A. Reading a short paragraph. Reading assesses cognitive function but not ADLs directly.

B. Telephoning a family member. This assesses communication skills but not practical ADLs.

C. Opening a bar soap package. This is the best choice because it directly assesses fine motor skills and the ability to perform a common ADL.

D. Sorting a collection of socks. Sorting socks assesses cognitive function and organization but not practical ADLs directly.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

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