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.

Answer and Explanation

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.

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Correct Answer is D

Explanation

The correct answer is choiced. "Describe your concerns about sleeping to me.".

Choice A rationale:

While offering frequent checks can provide some reassurance, it does not address the underlying fear the client is experiencing. It is more of a practical solution rather than a therapeutic one.

Choice B rationale:

Agreeing with the client’s fear without offering a solution or support can increase their anxiety. It is important to acknowledge their feelings but also to provide comfort and reassurance.

Choice C rationale:

Offering sleeping medication might help the client fall asleep, but it does not address the root cause of their fear. It is important to understand and address the client’s concerns directly.

Choice D rationale:

Asking the client to describe their concerns is a therapeutic approach that encourages them to express their fears.This allows the nurse to understand the client’s perspective and provide appropriate emotional support.

A. A client who plans to leave the facility against medical advice. B. A client who informs the nurse that they have made their funeral arrangements. C. A client who tells the nurse that the night shift nurse did not bring their medication. D. A client who has just experienced the death of their child.

Correct Answer is D

Explanation

The correct answer is choice D: A client who has just experienced the death of their child.

Choice A rationale:

Offering silence to a client who plans to leave the facility against medical advice might not be the most appropriate therapeutic communication technique. Silence in this situation could be misconstrued as ignoring the client's concerns or not addressing their reasons for wanting to leave. Active listening and open-ended questioning would likely be more effective in understanding and addressing the client's concerns.

Choice B rationale:

A client who informs the nurse that they have made their funeral arrangements is expressing thoughts and emotions that might require sensitive communication. Silence in this context could be interpreted as neglecting the client's need for support and empathy. The nurse should engage in a compassionate conversation and encourage the client to share their feelings.

Choice C rationale:

For a client who tells the nurse that the night shift nurse did not bring their medication, silence would not be the most suitable response. This situation calls for clarification and action, as the nurse needs to address the medication discrepancy promptly. Engaging in open communication and resolving the issue is essential here.

Choice D rationale:

A client who has just experienced the death of their child is likely overwhelmed with grief and intense emotions. In this scenario, using the therapeutic communication technique of silence can provide the client with a supportive space to process their feelings. Offering a moment of silence acknowledges the depth of their emotions and gives them the opportunity to express themselves when they are ready.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is D

Explanation

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