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 A
Explanation
A. Dysmenorrhea refers to painful menstruation, commonly associated with cramping in the lower abdomen.
B. Dysuria is painful or difficult urination, unrelated to menstrual pain.
C. Hematuria is the presence of blood in the urine, not associated with menstrual pain.
D. Dyschezia refers to painful bowel movements, not related to menstrual pain.
Correct Answer is B
Explanation
A. Hyperalgesia refers to increased sensitivity to pain stimuli, not specifically related to the inability to feel vibrations.
B. Peripheral neuropathy, a common complication of diabetes, often leads to sensory deficits, especially in distal extremities like the toes and feet.
C. Hyperparalysis is not a recognized term in neurology.
D. A lesion of the sensory cortex would likely present with broader sensory deficits rather than a specific loss of vibration sensation in the distal lower extremities.
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