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.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is D

Explanation

A. One minute may not provide a sufficient duration to declare absent bowel sounds, especially if the client has a slower bowel motility.
B.

Listening for 10 minutes in each quadrant is excessive and not supported by clinical guidelines. It would unnecessarily delay care and increase patient discomfort.

C. One minute in each quadrant might not provide an adequate assessment time.
D. This is the correct answer because clinical guidelines recommend auscultating for at least 5 minutes in each quadrant before concluding that bowel sounds are absent. This ensures sufficient time to detect infrequent bowel sounds and accurately assess the situation.

A. vas deferens B. Epididymis C. Prostate D. Testes

Correct Answer is D

Explanation

A. The vas deferens is a duct that transports sperm from the epididymis to the ejaculatory duct.
B. The epididymis is where sperm is stored and matures but not produced.
C. The prostate gland produces a fluid that contributes to semen but not sperm production.
D. The testes are responsible for producing sperm through the process of spermatogenesis.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an abdominal assessment, the nurse is unable to hear bowel sounds in a client's abdomen. How long should the nurse listen before reporting absent bowel sounds?

Correct Answer is D

Explanation

A male client with possible fertility problems asks the nurse where sperm is produced. Which answer should the nurse give the client?

Correct Answer is D

Explanation

A nurse is assessing a client's cranial nerves as part of a neurological examination. Which of the following actions should the nurse take to assess cranial nerve III?

A nurse is educating a client about blood cell formation in the body. The nurse documents the education and refers to blood cell formation as?

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

The nurse is assessing a client's joint for range of movement after falling in the shower. The nurse asks the client to move the right arm away from the center of the body. The nurse correctly documents the joint movement as?

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 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?

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.

The nurse is assessing a female client who reports painful menstruation. Which of the following should the nurse document in the client's record about painful menstruation?