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

Test Bank #1: RN Pharmacology Exams Test Bank #2: RN Medical-Surgical Exams Test Bank #3: RN Fundamentals Exams Test Bank #4: RN Maternal-Newborn Exams Test Bank #5: RN Anatomy and Physiology Exams Test Bank #6: RN Obstetrics and Pediatrics Exams Test Bank #7: RN Fluid and Electrolytes Exams Test Bank #9: RN Adult Health Test Bank #10: RN Dosage Calculation Test Bank #11: RN Community Health Exams Test Bank #12: RN Psychology Exams Test Bank #13: RN Nursing Care Of Children Test Bank #14: RN Foundations of Nursing Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Exam #1: RN Comprehensive predictor 2023 proctored exam Exam #2: Ati rn vati comprehensive predictor proctored exam Exam #3: Ati Rn Comprehensive Predictor Proctored Exam 2023 Exam #4: Rn Comprehensive Predictor 2023 Proctored Exam - St. Joseph Exam #5: RN Comprehensive Predictor Proctored Exam (National U CA San Diego) Exam #6: Ati rn comprehensive predictor 2023 retake proctored exam Exam #7: RN Hesi Exit Proctored Exam Exam #8: Hesi RN Exit proctored exam Exam #9: Hesi rn exit proctored exam Exam #10: Hesi Rn compass exit B proctored exam

Free Nursing Study Resources

Correct Answer is D

Explanation

A. Paralysis refers to the loss of muscle function in part of your body.
B. Hemiparesis is weakness on one side of the body.
C. Paraphasia is a language disorder where words get jumbled and sentences don't make sense.
D. Paresthesia is an abnormal sensation like tingling, burning, or numbness in the extremities often associated with nerve-related issues.

A. Report the finding, and refer the client to a specialist for further examination. B. Tell the client that a mass was felt, but is nothing to worry about. C. Instruct the client to return for a repeat assessment in 1 month. D. Continue the examination, and document the findings on the chart.

Correct Answer is A

Explanation

A firm, irregularly shaped mass found during a rectal examination could potentially indicate a serious condition such as a tumor or other pathology. It's essential to report such findings and refer the client to a specialist for further evaluation and appropriate diagnosis.
B. It's important not to dismiss or downplay the significance of finding a mass, as it could signify a serious health issue.
C. Waiting a month for reassessment could potentially delay necessary medical intervention if the mass is concerning.
D. While documentation is important, it's crucial to prioritize immediate reporting and referral for further evaluation when such findings are discovered.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assessing a client who reports an abnormal sensation of burning or tingling in extremities. Which of the following should the nurse document in the client's record?

Correct Answer is D

Explanation

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?

Correct Answer is A

Explanation

A client comes to the clinic and reports having weakness in the left arm and leg for the past week. The nurse should perform which type of neurological exam?

A nurse is assessing a client's fingers. The client complains of a swollen, painful knuckle and not being able to remove a ring from that finger. The nurse recognizes which of the following is the correct term for the affected joint.

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

A nurse is caring for a client who has difficulty swallowing medications and food. The nurse should recognize that the client is experiencing which of the following:

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 client states, "I can hear a crunching or grating sound when I kneel and have difficulty getting out of bed in the morning because of pain and stiffness." Which of the following should the nurse expect as an assessment finding?

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

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?