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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"B"},"E":{"answers":"A"},"F":{"answers":"A"}}
Explanation
Indigestion: This is a common symptom related to abdominal issues, and the nurse should assess it.
Nausea: Often indicates gastrointestinal distress and is important to evaluate.
Vomiting: A critical symptom that can signify a range of abdominal problems and warrants further assessment.
Non-essential:
Leg pain: Not typically associated with abdominal problems, making it non-essential for this assessment.
Headache: While it can be related to many conditions, it is not directly tied to abdominal problems.
Pruritus of the skin: Generally unrelated to abdominal symptoms, making it non-essential for this specific assessment.
Correct Answer is D
Explanation
A. Nodules, specifically rheumatoid nodules, can occur in RA, but they are not typically an early manifestation.
B. Fremitus is related to lung assessment and is not a manifestation of rheumatoid arthritis.
C. Tenderness in the soles of the feet is not a classic early manifestation of RA.
D. Joint swelling is one of the hallmark early signs of rheumatoid arthritis due to inflammation of the synovial membranes.
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