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
Explanation
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+.
Correct Answer is B
Explanation
Choice A rationale: Observing for facial symmetry is more relevant to Cranial Nerve VII (facial nerve).
Choice B rationale: Cranial nerve III (oculomotor nerve) is responsible for pupillary constriction. The nurse should check the pupillary response to light to assess the function of this cranial nerve.
Choice C rationale: Testing visual acuity is not specific to Cranial Nerve III but is more associated with Cranial Nerve II (optic nerve).
Choice D rationale: Eliciting the gag reflex is related to Cranial Nerve IX (glossopharyngeal nerve) and X (vagus nerve), not Cranial Nerve III.
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