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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Listening to speech primarily assesses cranial nerves related to speech and articulation, not cranial nerve II.
B. Identifying scented aromas assesses the olfactory nerve.
C. Clenching teeth primarily assess cranial nerve V (trigeminal nerve).
D. Cranial nerve II is the optic nerve responsible for vision. Testing visual acuity using a Snellen chart assesses this nerve's function.
Correct Answer is ["A"]
Explanation
A. Abdominal distention can occur due to gas accumulation from undigested lactose.
B. Visible peristalsis is not typically a specific clinical finding associated with lactose intolerance.
C. Hypoactive bowel sounds are not commonly associated with lactose intolerance.
D. Occasional diarrhea is a common symptom due to the inability to digest lactose properly.
E. Flatus or excessive gas production is a common symptom due to the fermentation of undigested lactose by intestinal bacteria.
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