While performing an assessment, the nurse presses the client's arm with the tip of her thumb, holds for a few seconds, and releases. The nurse observes the client as shown. What is the nurse assessing?

Pitting edema

Capillary refill

Skin temperature

Peripheral pulses

Answer and Explanation

The Correct Answer is A

A. Pitting edema: Pressing on the skin and observing how it rebounds (if it leaves an indentation) is used to assess for pitting edema, which indicates fluid retention in the tissues.

B. Capillary refill: This test involves pressing on the nail beds and observing the time it takes for color to return, not pressing on the arm.

C. Skin temperature: This is assessed by palpating the skin, not by pressing with the thumb.

D. Peripheral pulses: This involves palpating pulse points to assess their presence and strength, not pressing on the arm to check for edema.

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Correct Answer is A

Explanation

Rationale:
A. Second or third intercostal space at the left sternal border: Erb's point is located here, and it's a key area for listening to heart sounds, particularly the aortic and pulmonic valves.

B. The second intercostal space at the right sternal border: This area is typically used to auscultate the aortic valve.

C. Fifth intercostal space near the left midclavicular line: This area is used to auscultate the mitral valve, not Erb's point.

D. Third intercostal space at the left sternal border: This is the location for listening to the pulmonic valve, not Erb's point.

A. Use a low sodium seasoning to flavor food. B. Increase consumption of dairy products. C. Choose foods like bananas and sweet potatoes. D. Walk briskly 30 minutes per day. E. Consume two to three glasses of red wine daily.

Correct Answer is ["A","C","D"]

Explanation

A. Using low sodium seasoning can help reduce sodium intake, which is beneficial for hypertension management.

B. Increasing dairy products may not necessarily help with hypertension unless they are low-fat or fat-free options, but it’s not a primary strategy.

C. Foods like bananas and sweet potatoes are high in potassium, which helps counteract sodium's effects and supports healthy blood pressure.

D. Brisk walking for 30 minutes per day is a recommended exercise to help manage and prevent hypertension.

E. Consuming red wine is not recommended for hypertension; excessive alcohol intake can increase blood pressure.

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While performing an assessment, the nurse presses the client's arm with the tip of her thumb, holds for a few seconds, and releases. The nurse observes the client as shown. What is the nurse assessing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The traditional areas of auscultation of heart sounds include Erb's point, which is located at?

Correct Answer is A

Explanation

A nurse provides prevention strategies to a group of clients who are identified as at risk for hypertension. Which strategies should the nurse include? Select all that apply.

Correct Answer is ["A","C","D"]

Explanation

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