A client is admitted with a venous insufficiency of the right leg. What assessment findings does the nurse expect to find with this condition?
Poor hair growth
Weak pulse
Edema
Calf muscle atrophy (shrinkage)
Pale color
The Correct Answer is C
A. Poor hair growth is more associated with arterial insufficiency.
B. A weak pulse may suggest arterial, not venous, insufficiency.
C. Edema is a common finding in venous insufficiency due to fluid pooling in the extremities.
D. Muscle atrophy is not typically associated with venous insufficiency.
E. Pale color is more indicative of arterial insufficiency, while venous insufficiency may present with darkened or reddish skin.
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Correct Answer is D
Explanation
A. Fluid restriction by mouth is not typically necessary with opioid administration unless other health conditions require it.
B. A low salt diet is unrelated to opioid administration unless there are concurrent health issues like hypertension or fluid retention.
C. A chest x-ray is not indicated solely due to opioid use.
D. Stool softener medication is commonly prescribed alongside opioid medications because opioids frequently cause constipation due to reduced gastrointestinal motility.
E. Antidiarrheal medication is not needed, as opioids are more likely to cause constipation rather than diarrhea.
Correct Answer is E
Explanation
A. Palpate, inspect, percuss, and then auscultate is not the correct order, as inspection is always performed first.
B. Percuss, palpate, auscultate, and then inspect is incorrect, as inspection should come first.
C. Auscultate, inspect, percuss, and then palpate is also incorrect, as auscultation is typically the last step.
D. Inspect, auscultate, palpate, and then percuss is close but does not follow the standard order.
E. Inspect, palpate, percuss, then auscultate is the correct order for respiratory assessment, allowing for a thorough and systematic approach.