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 B

Explanation

Choice A rationale: Hyperalgesia refers to increased sensitivity to pain and is not evident in this scenario.

Choice B rationale: Inability to feel vibrations in the great toe or ankle bilaterally suggests peripheral neuropathy, which is a common complication of diabetes affecting the peripheral nerves.

Choice C rationale: Hyperparalysis is not a recognized term in the context of this assessment.

Choice D rationale: Lesion of the sensory cortex would likely have more widespread sensory deficits and wouldn't selectively affect the great toe and ankle.

A. Listen to the client's speech. B. Ask the client to read a Snellen chart. C. Ask the client to identify scented aromas D. Ask the client to clench his teeth

Correct Answer is D

Explanation

Choice A rationale: Listening to the client's speech is not related to the assessment of cranial nerve V.

Choice B rationale: Reading a Snellen chart is related to visual acuity and involves cranial nerve II, not cranial nerve V.

Choice C rationale: Identifying scented aromas is related to olfaction, which involves cranial nerve I, not cranial nerve V.

Choice D rationale: Cranial nerve V, the trigeminal nerve, is responsible for sensory input from the face and motor function such as biting and chewing. Asking the client to clench his teeth assesses the motor function of the trigeminal nerve.

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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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is B

Explanation

A nurse is assessing a client's cranial nerves. Which of the following methods should the nurse use to assess cranial nerve V?

Correct Answer is D

Explanation

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