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

Answer and Explanation

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.

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. HPV vaccination is recommended for both sexually active and non-sexually active individuals for preventive purposes. This statement restricts the vaccine unnecessarily.
B. This statement is correct. The HPV vaccine works best if administered before exposure to the virus, so it is not effective in treating existing HPV infections or genital warts.
C. While true that the HPV vaccine is typically recommended for individuals within a certain age range, this statement doesn't address the client's specific query about getting rid of existing genital warts.
D. Involving the physician in vaccine candidacy is a good step but doesn't directly address the client's query about HPV infection and genital warts.

A. Motor component of CN X and sensory component of CN VII B. Motor and sensory component of CN XI C. Motor component of CN IV D. Motor component of CN VII

Correct Answer is D

Explanation

A. Dysfunction of the motor component of CN X (vagus nerve) and sensory component of CN VII (facial nerve) would present with different symptoms, such as difficulty swallowing and impaired taste sensation, not the observed facial asymmetry and puffing of cheeks.
B. CN XI (accessory nerve) dysfunction primarily affects the sternocleidomastoid and trapezius muscles and wouldn't cause the observed facial asymmetry.
C. Dysfunction of CN IV (trochlear nerve) leads to issues with downward and inward eye movement, not the facial asymmetry described.
D. Dysfunction of the motor component of CN VII (facial nerve) leads to facial asymmetry during expressions and difficulty controlling facial muscles, which matches the observed findings.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is taking a health history from a female client. The client asks to get the vaccine for human papillomavirus (HPV) to get rid of genital warts. Which of the following statements should be the nurse's best response?

Correct Answer is B

Explanation

Correct Answer is D

Explanation

The nurse is preparing to complete a muscle strength assessment on a client. Which of the following assessment techniques should the nurse utilize?

The nurse is assessing a client who reports cessation of menses. The nurse should document the cessation of menses in the client's record as:

A client diagnosed with osteoporosis asks the nurse. "What is osteoporosis?" The nurse should provide which of the following explanations about osteoporosis?

A client tells the nurse about being very unsteady and has difficulty in maintaining balance. The nurses recognize which area of the brain is involved and require further assessment.

A client reports pain in the left wrist after falling while playing basketball. After assessing the wrist, which of the following assessment finding would make the nurse suspect a fracture?

The nurse is percussing a client's abdomen during a physical assessment. The nurse observes an area of dullness above the right costal margin of approximately 11 cm. Which of the following actions should the nurse take?

The student nurse is studying the functioning of the nervous system. Which of the following descriptions of the central nervous system is accurate?