A nurse is assessing a client with a history of heart failure who presents with severe edema in the lower extremities. The nurse would document the presence of +4 pitting edema after noting which finding?

Severe pitting, very swollen leg and indentation that lasts for a long time, 8 mm deep

Slight indentation, with no perceptible swelling of the leg. 2 mm deep

Moderate pitting, with indentation that subsides rapidly, 4 mm deep

Deep pitting, swollen leg, and indentation that remains for a short time, 6 mm deep

Answer and Explanation

The Correct Answer is A

A. +4 pitting edema is characterized by severe pitting that creates a deep indentation (greater than 8 mm) that remains for a prolonged period. This description matches the findings in option A.

B. This describes +1 pitting edema, which is not consistent with +4 edema.

C. This option describes +2 or +3 pitting edema, as the indentation subsides rapidly, which does not align with +4.

D. Although this describes deep pitting, the depth is less than 8 mm, which is not consistent with +4 edema.

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Correct Answer is C

Explanation

A. This description relates more to a sensory discrimination test, not graphesthesia.

B. This option does not accurately describe the graphesthesia test, which involves identifying shapes or numbers rather than just touch location.

C. In the graphesthesia test, the client closes their eyes while the nurse uses a blunt object to write a number or shape in the client's palm, and the client must identify what was written. This assesses the ability to recognize letters or numbers drawn on the skin.

D. This option describes a two-point discrimination test rather than graphesthesia, which focuses on identifying drawn shapes or numbers.

A. heroin B. ecstasy C. cocaine D. marijuana

Correct Answer is C

Explanation

Rationale:

A. Heroin use is generally associated with intravenous use and is less commonly linked to nasal septum perforation.

B. Ecstasy (MDMA) is primarily used in tablet form and is not typically associated with nasal use that would cause septal perforation.

C. Cocaine is frequently snorted, which can lead to irritation and damage to the nasal passages and septum, resulting in perforation.

D. Marijuana is usually smoked rather than snorted, and it is not commonly associated with nasal septum perforation.

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A nurse is assessing a client with a history of heart failure who presents with severe edema in the lower extremities. The nurse would document the presence of +4 pitting edema after noting which finding?

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