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. Cranial Nerve XI (Accessory nerve) is not involved in tongue movement; it controls muscles involved in head and shoulder movement.
B. Eye movement and control relate more to Cranial Nerves III, IV, and VI, which control eye muscles.
C. Hearing is primarily assessed by Cranial Nerve VIII (Vestibulocochlear nerve).
D. Cranial Nerve XI innervates the sternocleidomastoid and trapezius muscles, enabling movements like head turning and shoulder shrugging against resistance.

A. measure the circumference of the ankle. B. measure the calf at the widest point with a tape measure. C. check the dorsalis pedis pulse with the palm of the hand. D. compress the dorsalis pedis pulse, looking for blood return.

Correct Answer is B

Explanation

A. Measuring the circumference of the ankle is not a specific method for screening DVT.
B. Assessing the calf at its widest point with a tape measure can reveal differences in calf size, which might indicate swelling due to a DVT.
C. Checking the dorsalis pedis pulse assesses peripheral circulation but doesn't specifically screen for DVT.
D. Compressing the dorsalis pedis pulse to check for blood return is part of assessing peripheral circulation but doesn’t directly screen for DVT.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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?

Correct Answer is D

Explanation

The nurse is preparing to screen a client for deep vein thrombosis (DVT). Which of the following techniques should the nurse recognize as the appropriate technique to screen for DVT?

Correct Answer is B

Explanation

A nurse is taking a health history from a female client. The client asks to get the vaccine for human papillomavirus (HPV) to get rid of genital warts. Which of the following statements should be the nurse's best response?

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 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?

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 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?

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 educating a client on different areas of the brain. The nurse recognizes that which of the following statements concerning areas of the brain is correct?