The nurse is caring for an alert client who has been in bed for ...

[future617RT]

The nurse is caring for an alert client who has been in bed for three days. When performing a focused assessment, the nurse checks the skin of the legs and feet for which of the following?
 
  1. Dependent edema
  2. Foot drop
  3. Varicose veins
  4. Cyanosis

Question 2

The nurse is caring for a 70-year-old client who suddenly becomes confused and tells the nurse she has to go catch the bus. The nurse assesses which of the following before notifying the physician?
 
  1. Presence of an apical pulse rate
  2. The strength of the radial artery
  3. Presence of carotid pulses bilaterally
  4. The femoral pulses

[cswans24]

Answer to Question 1

1
Rationale: The feet and legs should be checked for dependent edema, which can increase the risk for skin breakdown. Foot drop is more likely to occur in the client with reduced level of consciousness, who is not moving the foot. Varicose veins and cyanosis would not be an anticipated risk of immobility unless other problems exist.

Answer to Question 2

3
Rationale: The client might be experiencing decreased blood flow to the brain as a result of reduced carotid perfusion. The nurse would lightly palpate for the carotid arteries, taking care to palpate only one side at a time, before notifying the physician. Presence of an apical pulse is indicated by the client's speaking, and radial artery strength and femoral pulses would not apply to the situation.