The patient has been found to have edema of the lower extremities. The nurse is assessing whether or not it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 4+ pitting edema because the rebound time is:

30 seconds to 1 minute

10-15 seconds

20 seconds

2-5 minutes

Answer and Explanation

The Correct Answer is D

A. 30 seconds to 1 minute. – This time frame is characteristic of 3+ pitting edema, not 4+.

B. 10-15 seconds. – This time frame is associated with 2+ pitting edema, which indicates a moderate level of fluid retention.

C. 20 seconds. – This time frame is associated with 3+ pitting edema.

D. 2-5 minutes. – 4+ pitting edema is the most severe form, where the indentation remains for 2-5 minutes, indicating significant fluid retention and possible cardiac or renal dysfunction.

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Correct Answer is C

Explanation

A. After palpating the abdomen – Palpation may alter bowel sounds by stimulating peristalsis, leading to inaccurate findings.

B. After checking for kidney tenderness – Checking for kidney tenderness (costovertebral angle tenderness) is unrelated to bowel auscultation and should not precede it.

C. Before percussing the abdomen – Auscultation should be done before percussion and palpation to avoid artificially stimulating bowel sounds.

D. Before inspecting the abdomen – Inspection should always come before auscultation to visually assess the abdomen for distension, symmetry, and discoloration before listening.

A. functional disease B. chronic disease C. acute disease D. contagious disease

Correct Answer is B

Explanation

A. Functional disease – A functional disease refers to a condition where symptoms occur without an identifiable structural or biochemical cause, such as irritable bowel syndrome (IBS).

B. Chronic disease – Diabetes mellitus is a lifelong condition requiring ongoing management through diet, medication, and lifestyle modifications.

C. Acute disease – Acute diseases have a sudden onset and short duration, such as influenza or appendicitis, unlike diabetes, which persists over time.

D. Contagious disease – Diabetes is not caused by infectious agents and cannot be transmitted from person to person.

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The patient has been found to have edema of the lower extremities. The nurse is assessing whether or not it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 4+ pitting edema because the rebound time is:

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Naxlex Comprehensive Predictor Exams

A nurse is checking a client's bowel sounds. At which of the following times should the nurse auscultate the client's abdomen?

Correct Answer is C

Explanation

When the patient asked the nurse how long it would take to "get over" the diabetes, the nurse explained that she will have this disease throughout her life. Diabetes mellitus is considered a/an:

Correct Answer is B

Explanation

The elderly patient is being assessed for skin turgor. Which of the following actions should the nurse take?

The protective response of body tissues to irritation, injury or pathogens is:

The nurse has been assigned to care for a 62 year-old man. After introducing herself to the patient and explaining that she will be performing a nursing assessment, what is the first area to be assessed after taking vital signs?

When performing the nursing physical assessment, the nurse uses head-to-toe organization. When using this method, the nurse begins with a:

When the color of the sclera is yellow due to bilirubin that infiltrates all tissues of the body it is called:

The nurse is obtaining a history of the patient's present illness. The PQRST system is being used for the interview. In this system the R is:

The main reason that auscultation precedes palpation of the abdomen is to:

The most frequently used skill in the physical nursing assessment is: