In which disease process should a nurse expect to see a client with the presence of pitting edema?

Liver Disease

Diabetes mellitus

End Stage Renal Disease

Colon Cancer

Answer and Explanation

The Correct Answer is A

(a) Liver Disease:

Pitting edema is commonly seen in liver disease, especially in conditions like cirrhosis. Liver disease can lead to hypoalbuminemia, where low levels of albumin in the blood cause fluid to leak into the interstitial spaces, resulting in edema. Additionally, liver disease often leads to portal hypertension, which can also contribute to the development of edema.

(b) Diabetes mellitus:

While diabetes can cause complications such as diabetic nephropathy, which may lead to fluid retention, pitting edema is not a primary symptom directly associated with diabetes mellitus. Diabetic patients may develop edema due to kidney issues, but it is not as directly associated as with liver disease.

End-stage renal disease (ESRD) can indeed cause significant fluid retention and edema, including pitting edema. The kidneys' inability to excrete excess fluid leads to its accumulation in tissues. However, the question seems to point towards liver disease, which directly leads to conditions causing pitting edema.

(d) Colon Cancer:

Colon cancer is not typically associated with pitting edema. While advanced cancer can lead to various complications, including fluid imbalances, it is not a primary cause of pitting edema. Edema related to cancer is often more localized and associated with tumor sites or treatment areas.

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Correct Answer is C

Explanation

(a) Mydriasis:

While mydriasis (dilated pupil) can be associated with cranial nerve III damage, it does not fully describe the range of symptoms expected with oculomotor paralysis. Cranial nerve III controls more functions than pupil dilation, such as eyelid elevation and certain eye movements.

(b) Normal eye movement:

Cranial nerve III paralysis would result in abnormal eye movement due to the loss of control over muscles responsible for moving the eye. Expecting normal eye movement would be incorrect since the paralysis affects the eye's ability to move properly.

Cranial nerve III (oculomotor nerve) paralysis leads to ptosis (drooping eyelid) because it innervates the levator palpebrae superioris muscle. It also affects the pupillary constrictor muscles, resulting in a dilated pupil (lack of pupillary constriction), making this the most comprehensive and accurate answer.

(d) The eye cannot look to the outside side:

Inability to look to the outside (lateral movement) is typically associated with cranial nerve VI (abducens nerve) paralysis, which controls the lateral rectus muscle. Cranial nerve III primarily affects vertical and medial movements, so this is not the expected finding.

A. Snellen chart B. Penlight C. Magazine D. Ophthalmoscope

Correct Answer is C

Explanation

A) Snellen chart:

The Snellen chart is used to assess distance vision, not near vision. It consists of letters or symbols arranged in rows, with the client typically asked to read from a specific distance to test visual acuity.

B) Penlight:

A penlight is primarily used to assess pupillary reactions and near vision tasks such as accommodation. It helps examine how the pupils respond to light and how well the eyes focus on near objects.

C) Magazine:

A magazine or similar reading material is commonly used to assess near vision. Clients are asked to read the text at a comfortable distance, evaluating their ability to focus on close-up objects and the clarity of their vision.

D) Ophthalmoscope:

An ophthalmoscope is used to examine the interior structures of the eye, such as the retina and optic nerve head. It is not used for assessing near vision but rather for diagnosing conditions affecting the eye's internal structures.

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In which disease process should a nurse expect to see a client with the presence of pitting edema?

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Naxlex Comprehensive Predictor Exams

The nurse read the patient's health history cranial nerve III oculomotor paralysis. Which of the following would the nurse expect?

Correct Answer is C

Explanation

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Correct Answer is C

Explanation

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