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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
When a patient is admitted with a complaint of chest pain, the priority assessment would be to determine whether the patient is experiencing an acute cardiac event, such as a heart attack. This would involve a comprehensive assessment that includes obtaining the patient's medical history, vital signs (blood pressure, heart rate, respiratory rate, oxygen saturation), performing a physical exam, and obtaining an electrocardiogram (ECG).
Other important factors to assess include the location and nature of the pain, any associated symptoms (such as shortness of breath or diaphoresis), the patient's current medications and medical history (including any history of heart disease or risk factors), and any recent procedures or interventions that may have led to the current presentation.
Prompt assessment and intervention are crucial in managing a patient with chest pain, as timely treatment can help to minimize damage to the heart muscle and prevent further complications. Therefore, any signs of an acute cardiac event should be immediately reported to the healthcare provider in charge, and appropriate interventions should be initiated promptly.
Correct Answer is B
Explanation
Objective data refers to measurable and observable information gathered during a patient assessment, such as physical signs, laboratory values, and other measurable data. In this case, the loss of hair on bilateral legs can be observed and measured, making it an objective finding. Options a, c, and d are all subjective data as they rely on the patient's report or description of their symptoms, which cannot be directly observed or measured.
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