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.

Answer and Explanation

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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Correct Answer is ["B","C","D"]

Explanation

Assessing unilaterally is not recommended as it may lead to missing important findings on one side.

A. This is moving his arms toward the midline of his body. B. This is moving his arms in a circular motion. C. This is extending his arms behind his back. D. This is moving his arms away from his body.

Correct Answer is B

Explanation

Circumduction is a movement that involves the circular rotation of a limb, such as an arm or leg, around a fixed point. When assessing the patient's range of motion, the nurse may ask the patient to perform circumduction of their arms to evaluate their ability to move their arms in a circular motion.

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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)

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