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 D

Explanation

A. Providing a safe and comfortable environment and applying critical thinking involves both objective and subjective data collection, not just one type.

B. While family members can contribute to patient care, the professional responsibilities of providing a safe environment and critical thinking in assessments fall to trained healthcare providers.

C. This process encompasses both subjective and objective data, as critical thinking requires integrating multiple types of information.

D. The actions described are essential professional responsibilities of trained healthcare providers, who must ensure a safe environment, apply critical thinking, and identify patient cues effectively.

A. Ask the client to identify scented aromas. B. Ask the click to read a Snellen chart. C. Listen to the client's speech. D. Ask the client to clench his teeth.

Correct Answer is A

Explanation

A. Asking the client to identify scented aromas assesses cranial nerve I (olfactory nerve), which is responsible for the sense of smell.
B. Reading a Snellen chart assesses cranial nerve II (optic nerve), which is related to vision.
C. Listening to the client's speech evaluates the function of cranial nerves V (trigeminal) and XII (hypoglossal), which are related to mastication and tongue movement, respectively.
D. Asking the client to clench his teeth tests cranial nerve V, which innervates the muscles of mastication.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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