A nurse is assessing a client's peripheral circulation. In which of the following locations should the nurse palpate to assess the posterior tibial pulse? (Selectable areas, or "Hot Spots," are outlined in the artwork below. Select only the outlined area that corresponds to your answer.)
Iliac
Femoral
Popliteal
Tibial
The Correct Answer is D
A. The iliac pulse is located near the pelvis and is not used for assessing circulation in the lower extremities.
B. The femoral pulse is located in the upper thigh, not near the posterior tibial area.
C. The popliteal pulse is found at the back of the knee and is higher than the posterior tibial location.
D. The posterior tibial pulse is correctly located behind the medial malleolus on the inner side of the ankle. This location is where the posterior tibial artery is accessible and is commonly used to assess blood flow to the lower extremities.
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Correct Answer is D
Explanation
A. Checking pupillary response to light assesses cranial nerve II (optic nerve).
B. Observing for facial symmetry primarily assesses cranial nerves VII (facial nerve) and possibly V (trigeminal nerve).
C. Testing for sense of smell assesses cranial nerve I (olfactory nerve).
D. Eliciting the gag reflex assesses cranial nerve IX (glossopharyngeal nerve) and also cranial nerve X (vagus nerve), making it the correct action to assess cranial nerve IX.
Correct Answer is A
Explanation
A. The bell of the stethoscope is best used to listen for low-pitched sounds, including some types of murmurs, and can help assess the quality and intensity of a cardiac murmur.
B. While palpation can provide some information about the heart's function (such as thrills), it is not the primary method for assessing the quality of a murmur.
C. A Doppler ultrasound device is used for measuring blood flow and can help in assessing murmurs but does not provide the quality assessment needed for characterizing a murmur.
D. Percussion is not typically used to evaluate murmurs; it is more useful for assessing the size and borders of organs.