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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. I: A grade I murmur is very faint and may not be heard immediately without careful listening. The description of a murmur heard immediately upon placing the stethoscope indicates it is a grade I.
B. X: There is no grade X in the standard grading scale for heart murmurs.
C. II: A grade II murmur is quiet but easily heard with a stethoscope and would generally be more audible than described.
D. III: A grade III murmur is moderately loud and would be heard without difficulty. The description suggests a quieter murmur.
Correct Answer is B
Explanation
A. Diaphragm on one side, bell on the opposite side: Suitable for a full cardiac examination, as it can assess both high and low-frequency sounds.
B. Diaphragm Only: Less suitable for a full cardiac examination because it may not effectively capture low-frequency sounds such as certain heart murmurs.
C. Bell on one side, Diaphragm on the opposite side: Effective for a full cardiac examination, as it can assess both high and low-frequency sounds.
D. Diaphragm and bell on same side: Allows for a complete assessment of heart sounds, though it may be less versatile than separate components on each side.
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