A nurse is preparing to document information about a client's lower legs, which are swollen with 6 mm edema. Which of the following information should the nurse document?
1+ pitting edema.
2+ pitting edema.
3+ pitting edema.
4+ pitting edema.
The Correct Answer is C
The correct answer is Choice C: 3+ pitting edema.
Choice A rationale:
1+ pitting edema refers to mild pitting edema. It is characterized by a slight indentation that disappears rapidly. A measurement of 6 mm edema is beyond the scope of 1+ pitting edema.
Choice B rationale:
2+ pitting edema indicates moderate pitting edema. It is characterized by a deeper indentation that takes a few seconds to rebound. While 6 mm edema might be associated with 2+ pitting edema, it is not the most accurate description.
Choice C rationale:
3+ pitting edema signifies moderately severe pitting edema. It is characterized by a noticeable indentation that remains for a short duration. A measurement of 6 mm edema aligns with 3+ pitting edema, making it the correct choice.
Choice D rationale:
4+ pitting edema represents severe pitting edema. It is characterized by a deep indentation that persists for a significant amount of time. 6 mm edema is not typically associated with 4+ pitting edema.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
The correct answer is choice b. Three-point.
Choice A rationale:
The four-point gait is used when a client can bear weight on both legs. It involves moving one crutch forward, followed by the opposite leg, then the other crutch, and finally the other leg. This gait provides maximum stability but is not suitable for non-weight-bearing conditions.
Choice B rationale:
The three-point gait is appropriate for clients who cannot bear weight on one leg. In this gait, both crutches and the affected leg move forward together, followed by the unaffected leg. This allows the client to keep weight off the injured leg while moving.
Choice C rationale:
The two-point gait is used when a client can bear partial weight on both legs. It involves moving one crutch and the opposite leg forward simultaneously, followed by the other crutch and leg. This gait is faster than the four-point gait but still provides some stability.
Choice D rationale:
The swing-through gait is used by clients who have good upper body strength and balance. It involves moving both crutches forward together and then swinging both legs forward past the crutches. This gait is not typically recommended for clients who need to keep weight off one leg.
Correct Answer is B
Explanation
The correct answer is choice B: A thready pulse.
Choice A rationale:
BUN (blood urea nitrogen) level of 18 mg/dL falls within the normal range, which is typically around 7-20 mg/dL. An elevated BUN might indicate dehydration or kidney dysfunction, but a value of 18 mg/dL does not necessarily suggest fluid volume deficit.
Choice B rationale:
A thready pulse is a weak and easily compressible pulse that indicates poor circulation and reduced fluid volume in the circulatory system. Vomiting and diarrhea lead to fluid loss, which can result in fluid volume deficit. Thus, a thready pulse is a significant finding in this context.
Choice C rationale:
Hemoglobin level of 15 g/dL is within the normal range for hemoglobin (usually around 12-16 g/dL for women and 14-18 g/dL for men). While vomiting and diarrhea can lead to mild dehydration, a hemoglobin level of 15 g/dL alone does not strongly suggest fluid volume deficit.
Choice D rationale:
Prominent neck veins are typically associated with increased central venous pressure, which can indicate fluid volume overload rather than fluid volume deficit. In the context of vomiting and diarrhea, neck veins are unlikely to become prominent due to volume depletion.
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