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 B

Explanation

A. Hepatomegaly refers to an enlarged liver.
B. Hematopoiesis is the process of blood cell formation that occurs primarily in the bone marrow.
C. Osteogenesis is the process of bone formation.
D. Splenomegaly refers to an enlarged spleen.

A. Recognizes this dullness as indicative of an enlarged liver, and refers the client to a provider B. Document the presence of hepatomegaly C. Ask additional health history questions regarding alcohol intake D. Recognizes this finding as normal, and proceed with the examination

Correct Answer is A

Explanation

A. Dullness above the right costal margin could indicate an enlarged liver. Referring the client to a healthcare provider is crucial for further evaluation and diagnosis.
B. Documenting hepatomegaly without further investigation or confirmation by a healthcare provider could be premature.
C. While alcohol intake can be a factor in liver conditions, additional history alone may not confirm the cause of the dullness. Direct evaluation by a healthcare provider is necessary.
D. Finding an area of dullness above the right costal margin, particularly of such magnitude, should prompt further investigation rather than being considered normal.

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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

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Explanation

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Correct Answer is A

Explanation

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