A nurse is caring for a client with severe bilateral lower extremity edema.

Nursing Assessment:

The client drove self to the Emergency Department. Stated, "My legs are swollen like balloons and I can hardly walk." The client has bilateral 4+ pitting edema from feet to knees. The nurse is preparing to assess the client's medical history. Which of the following should the nurse recognize to be the underlying cause of lower extremity edema?

Heart failure

Excess fluid retention

Excess fluid consumption

Pulmonary embolism

Answer and Explanation

The Correct Answer is A

A.   Heart failure can lead to fluid accumulation in the legs due to the heart's inability to effectively pump blood, causing increased pressure in the veins.
B.   Excess fluid retention or consumption might cause edema, but heart failure specifically impacts the heart's pumping function.
C.   Excess fluid consumption might contribute to temporary edema, but severe bilateral lower extremity edema is more likely due to a systemic issue like heart failure.
D.   While a pulmonary embolism can lead to edema in the legs, it typically presents with sudden onset and might not present with bilateral edema from feet to knees.

Nursing Test Bank

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Correct Answer is C

Explanation

A. The sigmoid is a part of the large intestine located in the left lower quadrant, so tenderness in the right lower quadrant is unlikely to be related to the sigmoid.
B. The liver is situated higher in the abdomen, typically more towards the right upper quadrant, and its tenderness wouldn't manifest in the right lower quadrant.
C. Tenderness in the right lower quadrant is a classic sign of appendicitis, suggesting inflammation of the appendix.
D. The gallbladder is positioned closer to the liver, in the right upper quadrant, and wouldn't typically cause tenderness in the right lower quadrant.

A. Dysmenorrhea B. Dysuria C. Hematuria D. Dyschezia

Correct Answer is A

Explanation

A. Dysmenorrhea refers to painful menstruation, commonly associated with cramping in the lower abdomen.
B. Dysuria is painful or difficult urination, unrelated to menstrual pain.
C. Hematuria is the presence of blood in the urine, not associated with menstrual pain.
D. Dyschezia refers to painful bowel movements, not related to menstrual pain.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

During an abdominal assessment, the nurse elicits tenderness on light palpation in the right lower quadrant. The nurse recognizes that this finding could indicate a problem with which organ?

Correct Answer is C

Explanation

The nurse is assessing a female client who reports painful menstruation. Which of the following should the nurse document in the client's record about painful menstruation?

Correct Answer is A

Explanation

The nurse is percussing a client's abdomen during a physical assessment. The nurse observes an area of dullness above the right costal margin of approximately 11 cm. Which of the following actions should the nurse take?

The nurse is describing how to perform a testicular self-examination to a client. Which of the following should be the appropriate statement by the nurse?

The nurse is performing a scrotal assessment on a male client. Which of the following findings of the scrotum should the nurse recognize as abnormal?

The physician comments that the client has abdominal borborygmic. The nurse recognizes that which of the following is the best description of borborygmic?

The nurse is performing a physical assessment of the client's mandible and temporal bone. The nurse recognizes that the articulation of the mandible and the temporal bone is called?

A nurse is assessing a client who has lactose intolerance. Which of the following will the nurse recognize as clinical findings associated with lactose intolerance? Select all that apply:

A nurse is taking a health history from a female client. The client asks to get the vaccine for human papillomavirus (HPV) to get rid of genital warts. Which of the following statements should be the nurse's best response?