A nurse is caring for a client with severe bilateral lower extremity edema.
Nursing Assessment:
The client drove self to the Emergency Department. Stated, "My legs are swollen like balloons and I can hardly walk." The client has bilateral 4+ pitting edema from feet to knees. The nurse is preparing to assess the client's medical history. Which of the following should the nurse recognize to be the underlying cause of lower extremity edema?
Heart failure
Excess fluid retention
Excess fluid consumption
Pulmonary embolism
The Correct Answer is A
A. Heart failure can lead to fluid accumulation in the legs due to the heart's inability to effectively pump blood, causing increased pressure in the veins.
B. Excess fluid retention or consumption might cause edema, but heart failure specifically impacts the heart's pumping function.
C. Excess fluid consumption might contribute to temporary edema, but severe bilateral lower extremity edema is more likely due to a systemic issue like heart failure.
D. While a pulmonary embolism can lead to edema in the legs, it typically presents with sudden onset and might not present with bilateral edema from feet to knees.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Osteoporosis involves a reduction in bone density, making bones weaker and more susceptible to fractures.
B. Osteoporosis doesn't refer to new bone growth; instead, it involves the weakening of existing bone structure.
C. While calcium intake is crucial for bone health, osteoporosis is a multifactorial condition influenced by various factors beyond just calcium intake.
D. Osteoporosis can occur in menopausal women due to hormonal changes, but it's not solely attributed to the lack of hormone replacement therapy. Hormones play a role in bone health, but osteoporosis is fundamentally about bone density loss.
Correct Answer is C
Explanation
A. Estimating the degree of flexion and extension in each joint primarily assesses the range of motion, not specifically muscle strength.
B. Measuring the degree of force required to overcome joint flexion or extension may assess resistance but doesn't directly evaluate muscle strength.
C. Applying an opposing force when the individual puts a joint in flexion or extension is an accurate method to assess muscle strength, as it evaluates the force the muscle can generate against resistance.
D. Observing muscles for contraction while lifting a heavy object evaluates muscle usage but doesn’t offer a standardized way to assess muscle strength.
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