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 D

Explanation

Choice A rationale: CN X (vagus nerve) and CN VII (facial nerve) are separate cranial nerves, and the described findings are more indicative of dysfunction in the motor component of CN VII.

Choice B rationale: CN XI (accessory nerve) is primarily involved in motor function related to the sternocleidomastoid and trapezius muscles. It is not likely to cause the described facial asymmetry.

Choice C rationale: CN IV (trochlear nerve) is responsible for eye movement and would not be directly related to the described facial findings.

Choice D rationale: The described findings, such as asymmetry when smiling or frowning, uneven lifting of the eyebrows, and escape of air when pressing against a puffed cheek, indicate dysfunction of the motor component of cranial nerve VII (facial nerve).

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?

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Naxlex Comprehensive Predictor Exams

Correct Answer is D

Explanation

The nurse is performing a rectal examination on a client and finds a firm, irregularly shaped mass. Which of the following is the next action the nurse should take?

Correct Answer is A

Explanation

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