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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Correct Answer is B

Explanation

A. Measuring the circumference of the ankle is not a specific method for screening DVT.
B. Assessing the calf at its widest point with a tape measure can reveal differences in calf size, which might indicate swelling due to a DVT.
C. Checking the dorsalis pedis pulse assesses peripheral circulation but doesn't specifically screen for DVT.
D. Compressing the dorsalis pedis pulse to check for blood return is part of assessing peripheral circulation but doesn’t directly screen for DVT.

A. Very deep pitting indentation of legs lasts several minutes. B. Deep pitting indentation of legs lasts a few minutes. C. Mild pitting, no perceptible swelling of the legs. D. Moderate pitting: indentation of legs subsides rapidly.

Correct Answer is A

Explanation

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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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is B

Explanation

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?

Correct Answer is A

Explanation

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

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