A nurse is performing a physical assessment of a patient who is experiencing fluid volume excess. Upon examination of the patient's legs, the nurse documents: Pitting edema; 8-mm pit. Pit remained for 4 minutes after pressing. What grade of edema has this nurse documented?
2+ Pitting Edema
3+ Pitting Edema
1+ Non-Pitting Edema
4+ Pitting Edema
The Correct Answer is D
A. 2+ Pitting Edema: This refers to moderate pitting edema where the indentation is approximately 4 mm and disappears within 10-15 seconds.
B. 3+ Pitting Edema: This refers to moderately severe pitting edema where the indentation is approximately 6 mm and may last longer than 1 minute but does not remain for as long as 4 minutes.
C. 1+ Non-Pitting Edema: This grade refers to mild pitting edema with a 2 mm indentation that quickly disappears within a few seconds.
D. 4+ Pitting Edema: 4+ pitting edema is characterized by a very deep pit (approximately 8 mm) that may last 2-5 minutes or more. This matches the scenario where the pit is 8 mm deep and remains for 4 minutes.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is choice C. "I will need palliative care to assist with treating my symptoms so that I can have quality of life across the span of my illness." Palliative care aims to improve the quality of life of patients and their families facing life-threatening illnesses. The goal of palliative care is to provide symptom management, pain relief, and support to patients and families throughout the course of their illness. Hospice care is a type of palliative care for patients with a life expectancy of six months or less, where the focus of care is comfort rather than curative treatment.
Correct Answer is B
Explanation
A. Ask the client which language they would like the written materials.While providing written materials in the client’s preferred language is important for communication, this does not directly address the client's vision loss. It may help with understanding but does not enhance their ability to see the materials.
B. Ensure the client has access to all corrective eyewear.This is the most appropriate intervention. Ensuring that the client has access to corrective eyewear, such as glasses or contact lenses, will help maximize their remaining vision. This is a practical and supportive action for someone with moderate vision loss.
C. Speak in a loud voice directly at the patient.Vision loss does not imply hearing impairment, so speaking in a loud voice is unnecessary and could be confusing or frustrating for the client. Communication should be clear and normal in volume, not assuming a hearing deficit.
D. Place the client close to the nurse's station.Placing the client close to the nurse’s station may enhance safety and allow for quicker assistance. However, it is not specifically related to addressing the client's vision loss and may not be necessary depending on their overall condition.
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