In which disease process should a nurse expect to see a patient with the presence of pitting edema?

Diabetes mellitus

Liver disease

End-stage renal disease

Colon cancer

Answer and Explanation

The Correct Answer is B

Choice A reason:

Diabetes mellitus is not typically associated with pitting edema unless it has led to a comorbid condition such as heart failure or kidney disease. Pitting edema is more commonly associated with fluid retention due to the body's inability to manage fluid balance, which is not a direct consequence of diabetes mellitus itself.

Choice B reason:

Liver disease, particularly cirrhosis, can lead to pitting edema. The liver's inability to produce albumin, a protein that helps maintain oncotic pressure in the blood vessels, and portal hypertension, which is an increase in the blood pressure within the portal vein system, can both contribute to the development of pitting edema.

Choice C reason:

End-stage renal disease can also cause pitting edema due to the kidneys' inability to excrete excess fluid. However, the edema associated with renal disease is often more generalized and not limited to the lower extremities.

Choice D reason:

Colon cancer is not typically associated with pitting edema unless it has metastasized and caused secondary complications that affect the liver or the heart. Pitting edema is not a direct symptom of colon cancer itself.

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Correct Answer is C

Explanation

Choice a reason:
Rhonchi are coarse, rattling respiratory sounds somewhat like snoring, usually caused by obstruction or secretion in the larger airways. They are not considered normal breath sounds and are typically heard in conditions such as chronic bronchitis.

Choice b reason:
Crackles are the sounds you will hear in a lung field that has fluid in the small airways. These sounds are commonly heard in patients with pneumonia, heart failure, and restrictive pulmonary diseases. They are not normal breath sounds.

Choice c reason:
Bronchovesicular sounds are normal breath sounds heard over the main bronchus area and over the upper right posterior lung field. They have a medium pitch and intensity and are heard on both inspiration and expiration. In a healthy individual, these sounds are expected to be heard in the 1st and 2nd intercostal spaces near the sternal body.

Choice d reason:
Tracheal breath sounds are harsh, high-pitched sounds heard when auscultating over the trachea in the neck. They are not normally heard over the intercostal spaces of the chest wall.

A. Conjunctiva B. Sclera of the eye C. Back of the neck D. Palms of the hands

Correct Answer is B

Explanation

Choice A Reason:
The conjunctiva can sometimes appear yellow in individuals with jaundice; however, it is not the most reliable area to inspect for jaundice. The conjunctiva may be affected by other factors such as environmental irritants or infections, which can alter its appearance.

Choice B Reason:
The sclera of the eye is the most reliable area to inspect for jaundice. The yellowing of the sclera, also known as scleral icterus, is a key indicator of jaundice. The sclera's white background provides a clear contrast, making any yellow discoloration more noticeable. This is particularly true in darker-skinned individuals, where skin changes may be less apparent.

Choice C Reason:
The back of the neck is not a reliable area to inspect for jaundice. Skin pigmentation and lighting can affect the visibility of yellowing, making it an unreliable indicator. Additionally, the back of the neck may have other skin changes unrelated to jaundice that could confuse the assessment.

Choice D Reason:
The palms of the hands are not the most reliable area to inspect for jaundice. While the palms may show yellowing, they are subject to various external factors such as manual labor or exposure to substances that can affect their color. Moreover, the palms' skin may be thicker and less transparent, making subtle changes in color more difficult to detect.

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In which disease process should a nurse expect to see a patient with the presence of pitting edema?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While auscultating a client's 1st and 2nd intercostal spaces, close to the sternal body, the nurse would document these normal breath sounds as which of the following?

Correct Answer is C

Explanation

A nurse is assessing a 64-year-old African-American client who has jaundice. The patient has a past medical history of alcoholism and liver cirrhosis. Which of the following areas is the most reliable for the nurse to inspect for jaundice?

Correct Answer is B

Explanation

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