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 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.

A. When the client sticks out the tongue it is in the midline and without tremors or deviation. B. Client follows an object with eyes without nystagmus or strabismus. C. Client demonstrates the ability to hear normal conversation. D. Client moves the head and shoulders against resistance with equal strength.

Correct Answer is D

Explanation

A. Cranial Nerve XI (Accessory nerve) is not involved in tongue movement; it controls muscles involved in head and shoulder movement.
B. Eye movement and control relate more to Cranial Nerves III, IV, and VI, which control eye muscles.
C. Hearing is primarily assessed by Cranial Nerve VIII (Vestibulocochlear nerve).
D. Cranial Nerve XI innervates the sternocleidomastoid and trapezius muscles, enabling movements like head turning and shoulder shrugging against resistance.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is performing an assessment and finds that the client has a non-tarry and black stool. Which of the following subjective data should the nurse document as normal findings consistent with non-tarry black stool?

Correct Answer is C

Explanation

The nurse tests the function of Cranial Nerve XI while performing a physical examination on a client. Which statement best describes the response the nurse should expect if Cranial Nerve XI is intact?

Correct Answer is D

Explanation

The nurse is providing health promotion teaching to a group of clients. The nurse should include in her teaching which of the following populations has a greater risk factor for osteoporosis.

The nurse is preparing to screen a client for deep vein thrombosis (DVT). Which of the following techniques should the nurse recognize as the appropriate technique to screen for DVT?

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes that this finding could indicate a problem with which organ?

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?

The nurse teaches a client that there are shock absorbers in the back to cushion the spine and to help it move. The client understands that which of the following is another name for shock absorbers:

A 60-year-old man has been told that he has benign prostatic hypertrophy (BPH). He expresses that his friend just died from prostate cancer and that he is concerned about dying from cancer. Which of the following is an appropriate response by the nurse?

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?

The nurse is completing a neurological assessment on a client who suffered from a motor vehicle accident (MVA). Which of the following findings should the nurse report to the practitioner immediately?