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 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.

A. Interphalangeal B. Tibiotalar C. Metacarpophalangeal D. Tarsometatarsal

Correct Answer is A

Explanation

A. Interphalangeal joints are the joints between the phalanges, since the client is unable to remove a ring, the most likely affected joint is the interphalangeal joint.
B. The Tibiotalar joint is the ankle joint.
C. Metacarpophalangeal joint refers to the joint between the metacarpal bones in the upper limbs and the phalanges.
D. Tarsometatarsal joints are the joints between the tarsal bones of the foot and metatarsal bones.

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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

The nurse is performing a rectal examination on a client and finds a firm, irregularly shaped mass. Which of the following is the next action the nurse should take?

Correct Answer is A

Explanation

A nurse is assessing a client's fingers. The client complains of a swollen, painful knuckle and not being able to remove a ring from that finger. The nurse recognizes which of the following is the correct term for the affected joint.

Correct Answer is A

Explanation

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The physician comments that the client has abdominal borborygmic. The nurse recognizes that which of the following is the best description of borborygmic?

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