The nurse is checking for edema in the lower extremities of a patient with Congestive heart failure. The nurse will do which of the following when checking for edema. (Select all that apply)
Grade the edema on a scale of +1 to +4.
Press the skin over the tibia.
Have the patient plantar flex their feet.
Check one limb only.
Correct Answer : A,B
When checking for edema in the lower extremities of a patient with Congestive heart failure, the nurse will grade the edema on a scale of +1 to +4 and press the skin over the tibia. Plantar flexing the feet is not necessary for assessing edema in the lower extremities, and checking only one limb is not sufficient as edema may occur in both legs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The nurse would use the skill of "inspection" first when examining the cardiovascular system of a patient. The inspection involves observing the patient's physical appearance, skin color, and breathing pattern. After inspection, the nurse would move on to palpation, percussion, and auscultation.
Palpation involves feeling for pulses and areas of tenderness, while percussion involves tapping the chest to assess the density of underlying tissues. Auscultation involves listening to heart sounds using a stethoscope.
Correct Answer is D
Explanation
Napping during the day can interfere with a person's ability to sleep at night, especially if it is done for long periods or close to bedtime. The nurse can provide education on proper sleep hygiene and recommend ways to establish a consistent sleep schedule that promotes restful sleep, such as avoiding caffeine and alcohol, practicing relaxation techniques, and limiting exposure to electronic devices before bedtime.
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