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.
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+.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A rationale: Abdominal distention is a common clinical finding in individuals with lactose intolerance due to the inability to digest lactose, leading to gas production and bloating.
Choice B rationale: Visible peristalsis is not a typical finding associated with lactose intolerance.
Choice C rationale: Hypoactive bowel sounds are not a characteristic feature of lactose intolerance.
Choice D rationale: Occasional diarrhea is a symptom of lactose intolerance, resulting from the presence of undigested lactose in the intestines.
Choice E rationale: Flatus (gas) is produced as a result of bacterial fermentation of undigested lactose in the colon, contributing to symptoms in individuals with lactose intolerance.
Correct Answer is A
Explanation
Choice A rationale: The affected joint described is an interphalangeal joint. Interphalangeal joints are found between the phalanges (fingers and toes).
Choice B rationale: Tibiotalar joints are found in the ankle, not the fingers.
Choice C rationale: Metacarpophalangeal joints are found between the metacarpal bones and the phalanges in the hand.
Choice D rationale: Tarsometatarsal joints are found in the foot, not the fingers.
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