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.
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+.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale: The Glasgow Coma Scale is used to assess the level of consciousness, not specific weakness in the extremities.
Choice B rationale: A complete neurological examination is appropriate to assess the client's weakness in the left arm and leg. This examination includes evaluating motor function, sensory function, coordination, reflexes, and cranial nerve function.
Choice C rationale: A muscular examination may focus on specific muscle groups but may not provide a comprehensive assessment of neurological function.
Choice D rationale: A neurologic recheck examination is not a standardized term and may not cover all aspects of a complete neurological assessment.
Correct Answer is A
Explanation
Choice A rationale: The basal ganglia are responsible for controlling voluntary movement and play a role in motor control.
Choice B rationale: Motor pathways of the spinal cord and brainstem synapse in the thalamus is not accurate. Motor pathways synapse in the spinal cord and brainstem, not the thalamus.
Choice C rationale: The cerebellum is primarily responsible for coordinating voluntary movements and maintaining balance, not speech and emotions.
Choice D rationale: While the hypothalamus does play a role in regulating body temperature and sleep, it is not the sole regulator, and its functions extend beyond these aspects.
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