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.

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Correct Answer is A

Explanation

A. Interphalangeal joints are the joints between the phalanges, since the client is unable to remove a ring, the most likely affected joint is the interphalangeal joint.
B. The Tibiotalar joint is the ankle joint.
C. Metacarpophalangeal joint refers to the joint between the metacarpal bones in the upper limbs and the phalanges.
D. Tarsometatarsal joints are the joints between the tarsal bones of the foot and metatarsal bones.

A. estimate the degree of flexion and extension in each joint. B. measure the degree of force that it takes to overcome joint flexion or extension. C. apply an opposing force when the individual puts a joint in flexion or extension. D. observe muscles for the degree of contraction when the individual lifts a heavy object.

Correct Answer is C

Explanation

A. Estimating the degree of flexion and extension in each joint primarily assesses the range of motion, not specifically muscle strength.
B. Measuring the degree of force required to overcome joint flexion or extension may assess resistance but doesn't directly evaluate muscle strength.
C. Applying an opposing force when the individual puts a joint in flexion or extension is an accurate method to assess muscle strength, as it evaluates the force the muscle can generate against resistance.
D. Observing muscles for contraction while lifting a heavy object evaluates muscle usage but doesn’t offer a standardized way to assess muscle strength.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client's fingers. The client complains of a swollen, painful knuckle and not being able to remove a ring from that finger. The nurse recognizes which of the following is the correct term for the affected joint.

Correct Answer is A

Explanation

The nurse is preparing to complete a muscle strength assessment on a client. Which of the following assessment techniques should the nurse utilize?

Correct Answer is C

Explanation

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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?