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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Paralysis refers to the loss of muscle function in part of your body.
B. Hemiparesis is weakness on one side of the body.
C. Paraphasia is a language disorder where words get jumbled and sentences don't make sense.
D. Paresthesia is an abnormal sensation like tingling, burning, or numbness in the extremities often associated with nerve-related issues.
Correct Answer is C
Explanation
A. Iron supplements typically lead to darker stools but may not necessarily present as a non-tarry black stool.
B. Dry heaves or vomiting could potentially indicate upper gastrointestinal bleeding but not specifically correlate with non-tarry black stool.
C. Consuming red meat can cause black stools due to its breakdown products, which is a normal finding.
D. Loss of appetite doesn't directly relate to stool color or consistency.
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