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 D

Explanation

A. A peritoneal friction rub is a grating sound caused by inflamed surfaces of the peritoneum rubbing together.
B. Borborygmi refers to loud, gurgling bowel sounds often heard with increased intestinal motility.
C. Hypoactive bowel sounds are abnormally decreased or absent bowel sounds.
D. Borborygmi describes the normal sounds made by the movement of gas and fluid in the intestines.

A. "A good time to examine your testicles is just before you take a shower." B. "If you notice an enlarged testicle or a painless lump, call your health care provider." C. "Perform a testicular examination at least once a week to detect the early stages of testicular cancer." D. "The testicle is egg-shaped and movable. It feels firm and has a lumpy consistency."

Correct Answer is B

Explanation

A. Timing for testicular examination isn't as crucial as recognizing changes in the testicles. While showering might facilitate the exam, it's not the only appropriate time.
B. Noticing an enlargement or painless lump is a crucial sign that requires immediate medical attention for evaluation.
C. Performing a testicular examination once a week might not be necessary for most individuals. Monthly self-examination is often recommended.
D. Describing the testicle's normal characteristics is helpful, but recognizing changes such as lumps or enlargements is more critical for self-examination.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The physician comments that the client has abdominal borborygmic. The nurse recognizes that which of the following is the best description of borborygmic?

Correct Answer is D

Explanation

The nurse is describing how to perform a testicular self-examination to a client. Which of the following should be the appropriate statement by the nurse?

Correct Answer is B

Explanation

The nurse has completed a peripheral vascular assessment on a client. Which of the following would the nurse document as expected findings?

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

The nurse is performing a scrotal assessment on a male client. Which of the following findings of the scrotum should the nurse recognize as abnormal?

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?

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?