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 A

Explanation

A. Osteoporosis involves a reduction in bone density, making bones weaker and more susceptible to fractures.
B. Osteoporosis doesn't refer to new bone growth; instead, it involves the weakening of existing bone structure.
C. While calcium intake is crucial for bone health, osteoporosis is a multifactorial condition influenced by various factors beyond just calcium intake.
D. Osteoporosis can occur in menopausal women due to hormonal changes, but it's not solely attributed to the lack of hormone replacement therapy. Hormones play a role in bone health, but osteoporosis is fundamentally about bone density loss.

A. estimate the degree of flexion and extension in each joint. B. measure the degree of force that it takes to overcome joint flexion or extension. C. apply an opposing force when the individual puts a joint in flexion or extension. D. observe muscles for the degree of contraction when the individual lifts a heavy object.

Correct Answer is C

Explanation

A. Estimating the degree of flexion and extension in each joint primarily assesses the range of motion, not specifically muscle strength.
B. Measuring the degree of force required to overcome joint flexion or extension may assess resistance but doesn't directly evaluate muscle strength.
C. Applying an opposing force when the individual puts a joint in flexion or extension is an accurate method to assess muscle strength, as it evaluates the force the muscle can generate against resistance.
D. Observing muscles for contraction while lifting a heavy object evaluates muscle usage but doesn’t offer a standardized way to assess muscle strength.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

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?

Correct Answer is C

Explanation

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

The nurse is percussing a client's abdomen during a physical assessment. The nurse observes an area of dullness above the right costal margin of approximately 11 cm. Which of the following actions should the nurse take?

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?

An adolescent male is brought to the emergency department with complaints of excruciating pain in his left testicle. Which of the following should be the priority action by the nurse?

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

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?