A client drove himself to the urgent care center for Legs that look like balloons and difficulty walking. The nurse assesses 4+ edema of both legs based upon which finding?

Very deep pitting indentation of legs lasts several minutes.

Deep pitting indentation of legs lasts a few minutes.

Mild pitting no perceptible swelling of the legs.

Moderate pitting: indentation of legs subsides rapidly.

Answer and Explanation

The Correct Answer is A

Choice A rationale: 4+ edema is characterized by very deep pitting indentation of the legs that lasts several minutes. This indicates severe fluid retention and significant swelling.

Choice B rationale: Deep pitting indentation lasting a few minutes is more indicative of 2+ or 3+ edema, not 4+.

Choice C rationale: Mild pitting with no perceptible swelling is more indicative of 1+ edema, not 4+.

Choice D rationale: Moderate pitting with rapid subsidence is indicative of 3+ edema, not 4+.

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Correct Answer is C

Explanation

Choice A rationale: Dull throbbing pain that increases with rest is less suggestive of a fracture.

Choice B rationale: A dull ache may be present with various conditions and is not specific to a fracture.

Choice C rationale: Sharp pain that increases with movement is indicative of a possible fracture, as movement can cause the fractured ends of the bone to rub against each other.

Choice D rationale: Deep pain in the wrist is nonspecific and may not be strongly indicative of a fracture.

A. Tell the adolescent, everything will be fine and there’s nothing to worry about. B. Complete an assessment and notify the emergency department physician immediately. B. Perform a focused assessment and document. C. Document pain assessment as normal

Correct Answer is B

Explanation

Choice A rationale: Telling the adolescent that everything will be fine without a thorough assessment may delay necessary interventions.
Choice B rationale: Excruciating pain in the testicle requires immediate attention since it could be an indication of testicular torsion. The nurse should complete an assessment and notify the emergency department physician promptly.
Choice C rationale: While documentation is important, the priority is to address the immediate needs of the adolescent in severe pain.
Choice D rationale: Documenting pain assessment as normal is not appropriate when the client is experiencing excruciating pain.

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A client drove himself to the urgent care center for Legs that look like balloons and difficulty walking. The nurse assesses 4+ edema of both legs based upon which finding?

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Naxlex Comprehensive Predictor Exams

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