The nurse is checking for edema in the lower extremities of a patient with Congestive heart failure. The nurse will do which of the following when checking for edema. (Select all that apply)
Grade the edema on a scale of +1 to +4.
Press the skin over the tibia.
Have the patient plantar flex their feet.
Check one limb only.
Correct Answer : A,B
When checking for edema in the lower extremities of a patient with Congestive heart failure, the nurse will grade the edema on a scale of +1 to +4 and press the skin over the tibia. Plantar flexing the feet is not necessary for assessing edema in the lower extremities, and checking only one limb is not sufficient as edema may occur in both legs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
The sense of taste is primarily mediated by the facial nerve (cranial nerve VII) and the glossopharyngeal nerve (cranial nerve IX). However, testing the function of specific cranial nerves such as the hypoglossal nerve (cranial nerve XII) or cranial nerve XI (11) is not directly related to evaluating the patient's ability to taste. Therefore, options a, b, and c would not be the most appropriate actions for the nurse to take in this scenario.
Correct Answer is A
Explanation
The nurse would describe this as tinnitus, which is a sensation of hearing sound when no external sound is present. Tinnitus is commonly described as ringing in the ears, but can also be perceived as buzzing, humming, hissing, or other sounds. Tinnitus can be caused by a variety of factors, including age-related hearing loss, exposure to loud noises, ear infections, certain medications, and underlying medical conditions such as high blood pressure, thyroid disorders, or head and neck injuries. It is important for the patient to see a healthcare provider to determine the underlying cause and appropriate treatment.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today