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

A.   4+ edema is characterized by very deep pitting, where the indentation remains for an extended period (several minutes), indicating severe fluid accumulation in the tissue.
B.   Deep pitting that lasts for a few minutes is more consistent with 2+ or 3+ edema, not the severe 4+ edema described.
C.   Mild pitting with no perceptible swelling does not align with 4+ edema; this level of pitting suggests minimal fluid accumulation.
D.   Moderate pitting where the indentation subsides rapidly is indicative of 2+ edema, not the profound swelling described as 4+ edema.

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Correct Answer is B

Explanation

A. Reassurance is important, but it should be given after a thorough assessment and appropriate actions have been taken.
B. Completing an assessment and promptly informing the physician allows for timely intervention in case of testicular torsion or other serious conditions causing severe testicular pain.
C. Performing a focused assessment is crucial but shouldn't delay immediate notification of the physician in such a critical situation.
D. Documenting pain assessment is important but not the priority when a client presents with severe, acute pain in a sensitive area like the testicles.

A. Flexion B. Extension C. Abduction D. Adduction

Correct Answer is C

Explanation

A. Flexion refers to bending a joint, usually decreasing the angle between two body parts.
B. Extension refers to straightening or increasing the angle between two body parts.
C. Abduction involves moving a body part away from the midline or center of the body.
D. Adduction involves moving a body part toward the midline or center of the body.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An adolescent male is brought to the emergency department with complaints of excruciating pain in his left testicle. Which of the following should be the priority action by the nurse?

Correct Answer is B

Explanation

The nurse is assessing a client's joint for range of movement after falling in the shower. The nurse asks the client to move the right arm away from the center of the body. The nurse correctly documents the joint movement as?

Correct Answer is C

Explanation

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