Health Assessment - EXAM 1 (ELSEVIER AQ)

A client presents with bilateral leg pain and cramping in the lower extremities. The client has a history of cardiovascular disease, diabetes, and varicose veins. To guide the assessment of the pain and cramping, the nurse should include which question when completing the initial assessment?

"Does walking for long periods of time increase your pain?"

A client complains of foot pain and is diagnosed with arterial insufficiency. The nurse provides teaching about what the client can do to increase arterial dilation and to decrease foot pain. The nurse concludes that further teaching is needed when the client states, "I will"

"Elevate my foot"

A client develops a non-healing ulcer of a lower extremity and complains of leg cramps after walking short distances. The client asks the nurse what causes these leg pains. The nurse's best response is?

"Pain occurs in the legs while walking because there is lack of oxygen to the muscles".

A nurse is caring for a client that has been admitted with right sided heart failure. The nurse notes that the client has dependent edema around the area of the feet and ankles. In order to characterized the severity of the edema, the nurse presses the medial malleolus area and notes an 8 mm depression after release. This nurse understands that the edema should be documented as?

+4

A mental health nurse is admitting a client with anorexia nervosa. When obtaining the history and physical assessment, the nurse expects the client's condition to reveal what?

Amenorrhea

Nursing care of a client with a fractured hip should include the assessment of pedal pulses. The nurse should assess for which important characteristics of the pedal pulses?

Amplitude and symmetry

A nurse is caring for a postoperative client who had a gastrectomy. What early client response indicates that peristalsis has returned?

Borborygmi are auscultated

A client with DM is given instructions about foot care. The nurse determines that the instructions are understood when the clients states, "I will:

Break in my new shoes over the course of several weeks.

A nurse is teaching a group of clients with peripheral vascular disease about a smoking cessation program. Which physiological effect of nicotine should the nurse explain to the group?

Constriction of the peripheral vessels increases the force of flow.

A client with a history of food intolerance has abdominal pain, abdominal distention, and a feeling of fullness. The client is admitted to the hospital for diagnostic testing. What specific information should the nurse collect when performing the nursing admission history and physical?

Detailed characteristics of the pain

A client admitted to the hospital has edematous ankles. What should the nurse do to best reduce edema of the lower extremities?

Elevate the legs.

The nurse assesses an edematous client and recalls that edema occurs in what extracellular fluid compartment?

Interstitial

A client arrives at the outpatient clinic with a painful leg ulcer, and the nurse performs a physical assessment. Which clinical findings in the lower extremity support a diagnosis of an arterial ulcer?

Lack of hair Thickened toenails Pain at the ulcer site Diminished pedal pulse

A client comes to the outpatient clinic with a large leg ulcer. The clinical finding that supports the diagnosis of arterial ulcer is:

Pain at the ulcer site

A 3-week-old infant is admitted with a tentative diagnosis of hypertrophic pyloric stenosis. Before conducting the admission assessment of the abdomen the nurse moves the infant's legs in a bicycling type motion. How does this help the nurse's assessment?

Relaxes abdominal muscles

The nurse plans to perform an abdominal assessment of a 10-year-old child with suspected appendicitis. List in order of priority the techniques the nurse should use when assessing this child's abdomen.

Warming the stethoscope's diaphragm Auscultating for bowel sounds

The nurse is providing instructions about foot care for a client with DM. What should the nurse include in the instructions?

Wear shoes when out of bed and dry between the toes after bathing.

What is the most objective way that a nurse can assess the extent of edema in a client?

Weighing the patient