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 brainstem is involved in basic life functions such as breathing, heart rate, and consciousness.
Choice B rationale: The cerebellum is primarily responsible for coordination, balance, and muscle tone. Unsteadiness and difficulty maintaining balance often indicate issues with the cerebellum and warrant further assessment.
Choice C rationale: The extrapyramidal tract is associated with motor function and does not play a primary role in balance and coordination.
Choice D rationale: The thalamus is involved in relaying sensory information but is not the primary center for balance and coordination.
Correct Answer is C
Explanation
Choice A rationale: Plantarflexion of the foot is not part of the Phalen test. Choice B rationale: Dorsiflexion of the foot is not part of the Phalen test.
Choice C rationale: To perform the Phalen test, the client should hold both hands back to back while flexing the wrists 90 degrees for 60 seconds. This test helps assess for symptoms of carpal tunnel syndrome.
Choice D rationale: Hyperextension of the wrists with the palmar surface of both hands touching is not the correct position for the Phalen test.
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