NR-304 Health Assessment II - Set 1 - Part 3

Correct Answer: Four plus, the anchor printed on this sheet

The item hands the nurse an anchor and expects it to be read. On a zero to four plus sheet, bounding is four plus; the course's own zero to three plus scale does not govern another facility's form. Option a is incorrect because three plus is the bounding grade only on the zero to three plus scale this course teaches. Entering it on a sheet that reserves three plus for full but not bounding understates the finding. Option c is incorrect because two plus means normal amplitude on both scales, and a full bounding pulse is not normal on either. Bounding accompanies fever, anemia, anxiety and hyperthyroidism and deserves to be recorded as abnormal. Option d is incorrect because altering a facility form invites confusion rather than resolving it, and no discrepancy exists once the printed anchor is used. Grading against the scale in front of you is the whole skill.

Correct Answer: Involuntary rigidity, suggesting peritoneal inflammation

Involuntary rigidity is a constant boardlike hardness that does not relax with warmth, breathing or distraction, and it points to peritoneal inflammation. Voluntary guarding always eases once the trigger for tensing is removed. Option b is incorrect because the nurse already warmed both hands and the hardness persisted. Cold-induced tensing resolves as soon as the stimulus is gone, which makes it the easiest of these explanations to exclude. Option c is incorrect because a ticklish client relaxes with conversation or with fingers curled around the stethoscope. Talking the client through the examination changed nothing here, so ticklishness cannot account for a wall this firm. Option d is incorrect because well-developed muscle still yields and moves with respiration when the person is relaxed. Hours of worsening pain paired with unyielding hardness describe pathology rather than fitness.

Correct Answer: A foot that has turned cold with mottled skin

A limb that has newly become cold and mottled has lost arterial inflow, and that failure is measured in hours. Graded edema, chronic staining and a months long change in walking distance all tolerate delay. Option a is incorrect because moving from one plus to two plus is a change within the mild half of the scale, where the leg still does not look swollen. It warrants a note and reassessment, not immediate action. Option b is incorrect because hemosiderin deposition accumulates across months of venous hypertension and cannot extend meaningfully in one shift. Staining marks damage already done rather than tissue dying now. Option c is incorrect because a shortening claudication distance signals disease progression that does need evaluation, yet it describes a limb still perfused at rest. Prompt referral is right; displacing a cold limb from first place is not.

Correct Answer: Calcified vessels make the index uninterpretable here

An index above one point four means the vessels are so calcified that the cuff cannot compress them, a common finding in long standing diabetes, so the value is uninterpretable rather than reassuring. Option a is incorrect because absent pulses, toe hair loss and a dry punched out ulcer over a metatarsal head are arterial findings; the physical examination outweighs a number the calcified vessels have inflated. Option b is incorrect because moderate disease corresponds to a value well below zero point nine, and this result is far above that range; a high index does not grade severity on the same scale. Option d is incorrect because normal distal amplification puts a healthy ankle pressure only slightly above the arm, giving a ratio near one point zero to one point four, not a reading that exceeds that ceiling.

Correct Answer: Repositioning a client's legs below heart level hourly

Once the nurse has determined that the limb should stay dependent, carrying out that position on a schedule is a routine task with a known outcome. Judging, deciding and evaluating are all nursing assessment. Option a is incorrect because classifying an ulcer requires weighing location, edges, drainage, temperature and pulses against each other. That reasoning determines whether the leg is elevated or dangled, and it belongs to the nurse. Option c is incorrect because clearing a client for compression means assessing arterial supply first, and the decision ultimately rests with the provider. An assistant cannot judge whether inflow will tolerate being squeezed. Option d is incorrect because evaluating understanding is the final step of the teaching process and requires interpreting what the client says and does. Reinforcing a taught point is allowed; judging whether learning occurred is not.

Correct Answer: Pulses present and normal at 2+

Venous disease obstructs drainage, not arterial inflow, so the foot stays warm and the dorsalis pedis and posterior tibial pulses remain present and normal at 2+. Weak or absent pulses would point to arterial disease instead. Option b is incorrect because a weak thready pulse describes reduced arterial delivery. Some study guides list it under venous insufficiency, but that imports the arterial picture by mistake; venous disease leaves pulse amplitude untouched. Option c is incorrect because absent pulses and delayed capillary refill mean the limb is not receiving enough arterial blood. Refill is a perfusion measure and stays normal when only the drainage side of the circulation has failed. Option d is incorrect because a bounding pulse reflects a high output or hyperdynamic state such as fever, anemia or thyrotoxicosis. Incompetent venous valves do not raise the volume or force ejected into the arteries.

Correct Answer: Elevate the legs above heart level

Venous symptoms are worst after prolonged standing and are relieved by elevation, which removes the hydrostatic column pressing fluid into the tissue. Elevating above heart level, walking and ankle pumps are the core of venous self care. Option a is incorrect because dangling belongs to arterial disease, where dependency uses gravity to improve inflow and relieve rest pain. In venous disease dependency makes the swelling and aching worse rather than better. Option b is incorrect because external heat does not correct valvular reflux and risks burning skin that is already fragile from stasis changes. Moisturizing and daily inspection protect that skin far better. Option d is incorrect because sitting still switches off the calf muscle pump, which is the venous system's only motor. Walking and ankle pumping move blood proximally, so stillness prolongs the congestion instead of easing it.

Correct Answer: Grade three, fair, against gravity only

Grade three is the gravity grade. The client achieves full range against gravity but tolerates no resistance at all, which places the performance at fifty percent of normal and the word grade fair. Option a is incorrect because that grade describes active movement only when gravity has been removed, with the limb supported in a horizontal plane. This client raised the leg straight up, which is a better performance. Option c is incorrect because a good grade requires the limb to hold against some examiner resistance through full range. Any resistance at all collapsed this movement, so the performance falls one grade below that. Option d is incorrect because normal strength means full range against gravity while the examiner pushes with full resistance. Nothing here approaches that standard, and grading it as normal would erase a real deficit from the record.

Correct Answer: Assisting the client to reposition the legs

Repositioning is a standard, predictable task with a known outcome, so it may be delegated with clear direction. Assessment, interpretation of findings and client teaching stay with the registered nurse. Option a is incorrect because locating and grading a pulse with a Doppler requires judgment about signal quality and amplitude, and in arterial disease that finding drives decisions the nurse alone is accountable for. Option b is incorrect because deciding what a new color change on the toes means is clinical interpretation; assistive personnel may report what they see, but they cannot analyze it or act on it. Option c is incorrect because client education is a nursing responsibility that cannot be handed off; foot care teaching carries safety content about heat, barefoot walking and lotion placement that needs professional judgment.

Correct Answer: Four plus, the bounding grade on that scale

A grade only means what its own anchor says. This record defines four plus as bounding, so a bounding pulse is charted four plus on that form even though this course's own scale stops at three plus. Option b is incorrect because the ceiling of one scale cannot be imposed on a different instrument. The stem supplied its own anchors, and on those anchors three plus means full rather than bounding. Option c is incorrect because two plus is defined here as normal amplitude, and a bounding vessel is not normal on any of these instruments. Charting it that way would hide a hyperkinetic finding from the next nurse. Option d is incorrect because no grade carries the same meaning across every scale in use, which is the whole point of reading the anchor. Here full and bounding are deliberately given separate grades.