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

A.   4+ edema is characterized by very deep pitting, where the indentation remains for an extended period (several minutes), indicating severe fluid accumulation in the tissue.
B.   Deep pitting that lasts for a few minutes is more consistent with 2+ or 3+ edema, not the severe 4+ edema described.
C.   Mild pitting with no perceptible swelling does not align with 4+ edema; this level of pitting suggests minimal fluid accumulation.
D.   Moderate pitting where the indentation subsides rapidly is indicative of 2+ edema, not the profound swelling described as 4+ edema.

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Correct Answer is D

Explanation

A. Listening to speech primarily involves cranial nerves related to speech production (e.g., CN V, CN VII, CN XII) but not specifically for CN V.
B. Reading a Snellen chart assesses visual acuity, primarily involving cranial nerve II (optic nerve).
C. Identifying scented aromas involves olfactory nerve (cranial nerve I) assessment.
D. Asking the client to clench their teeth evaluates the function of the muscles of mastication, which is controlled by cranial nerve V (trigeminal 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

A firm, irregularly shaped mass found during a rectal examination could potentially indicate a serious condition such as a tumor or other pathology. It's essential to report such findings and refer the client to a specialist for further evaluation and appropriate diagnosis.
B. It's important not to dismiss or downplay the significance of finding a mass, as it could signify a serious health issue.
C. Waiting a month for reassessment could potentially delay necessary medical intervention if the mass is concerning.
D. While documentation is important, it's crucial to prioritize immediate reporting and referral for further evaluation when such findings are discovered.

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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 D

Explanation

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Correct Answer is A

Explanation

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