The nurse is thoroughly assessing the client for any peripheral vascular problems. The client requested the nurse to state exactly what the nurse was looking for during the assessment

Question

Which of the following statements by the nurse are unexpected? Standard Text: Select all that apply. 1. "I am feeling your feet to see how warm they are.".
2. I am looking for hair on your toes.".
3. I am going to perform the Trendelenburg's test to see how well the radial and ulnar arteries are supplying blood to your hand.".
4. I am going to test your ability to feel sensations by giving you an injection.".
5. "I am going to perform the Allen's test to see if you have any varicose veins.".

Answer 1

3,4,5
Rationale 1: "I am feeling your feet to see how warm they are.". Warmth felt at the distal portions of the extremities indicate that the client is receiving an adequate amount of arterial blood flow to those areas.
Rationale 2: "I am looking for hair on your toes.". Hair growth on the client's toes indicates that the client is receiving an adequate amount of arterial blood flow to the toes. This is especially helpful when the client routinely shaves the hair from the legs.
Rationale 3: "I am going to perform the Trendelenburg's test to see how well the radial and ulnar arteries are supplying blood to your hand.". The Trendelenburg's test is used to determine varicose veins.
Rationale 4: "I am going to test your ability to feel sensations by giving you an injection.". The nurse should assess the client's ability to feel sensations by using the sharp and dull ends of a safety pin. An adequate ability to feel sensations indicates adequate arterial blood flow.
Rationale 5: "I am going to perform the Allen's test to see if you have any varicose veins.". The Allen's test is used to determine if the client has problems with arterial blood flow from the radial and ulnar arteries to the client's hand.