A client drove himself to the urgent care center for Legs that look like balloons and difficulty walking. The nurse assesses 4+ edema of both legs based upon which finding?

Very deep pitting indentation of legs lasts several minutes.

Deep pitting indentation of legs lasts a few minutes.

Mild pitting no perceptible swelling of the legs.

Moderate pitting: indentation of legs subsides rapidly.

Answer and Explanation

The Correct Answer is A

Choice A rationale: 4+ edema is characterized by very deep pitting indentation of the legs that lasts several minutes. This indicates severe fluid retention and significant swelling.

Choice B rationale: Deep pitting indentation lasting a few minutes is more indicative of 2+ or 3+ edema, not 4+.

Choice C rationale: Mild pitting with no perceptible swelling is more indicative of 1+ edema, not 4+.

Choice D rationale: Moderate pitting with rapid subsidence is indicative of 3+ edema, not 4+.

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Correct Answer is C

Explanation

Choice A rationale: The sigmoid is part of the large intestine and is located in the left lower quadrant.

Choice B rationale: The liver is located in the right upper quadrant.

Choice C rationale: Tenderness in the right lower quadrant during light palpation is a potential indication of appendicitis. The appendix is located in the lower right quadrant of the abdomen.

Choice D rationale: The gallbladder is typically located in the right upper quadrant, and tenderness in the right lower quadrant is not directly associated with gallbladder issues.

A. Report the finding, and refer the client to a specialist for further examination. B. Tell the client that a mass was felt, but is nothing to worry about. C. Instruct the client to return for a repeat assessment in 1 month. D. Continue the examination, and document the findings on the chart.

Correct Answer is A

Explanation

Choice A rationale: Finding a firm, irregularly shaped mass during a rectal examination raises concerns about the possibility of colorectal pathology, including cancer. The nurse should report the finding and refer the client to a specialist for further examination and diagnostic testing.

Choice B rationale: Dismissing the mass without further investigation may lead to a delay in diagnosis and appropriate treatment.

Choice C rationale: Instructing the client to return for a repeat assessment in 1 month is not appropriate when a potentially serious finding is present. Immediate referral for further evaluation is necessary.

Choice D rationale: Continuing the examination without addressing the finding and obtaining appropriate follow-up could compromise the client's health and delay necessary interventions.

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A client drove himself to the urgent care center for Legs that look like balloons and difficulty walking. The nurse assesses 4+ edema of both legs based upon which finding?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is A

Explanation

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