The patient has been found to have edema of the lower extremities. The nurse is assessing whether or not it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 4+ pitting edema because the rebound time is:

30 seconds to 1 minute

10-15 seconds

20 seconds

2-5 minutes

Answer and Explanation

The Correct Answer is D

A. 30 seconds to 1 minute. – This time frame is characteristic of 3+ pitting edema, not 4+.

B. 10-15 seconds. – This time frame is associated with 2+ pitting edema, which indicates a moderate level of fluid retention.

C. 20 seconds. – This time frame is associated with 3+ pitting edema.

D. 2-5 minutes. – 4+ pitting edema is the most severe form, where the indentation remains for 2-5 minutes, indicating significant fluid retention and possible cardiac or renal dysfunction.

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Correct Answer is D

Explanation

A. Nursing assessment – A nursing assessment is the broader process of gathering patient information, including subjective and objective data, but does not specifically refer to a body system review.

B. Nursing interview – A nursing interview is a method used to gather subjective data from the patient, but it does not systematically review all body systems.

C. Health history – A health history includes past medical conditions, surgeries, and family history but does not systematically assess all body systems.

D. Review of systems – The review of systems (ROS) is a structured approach where the nurse systematically collects data about normal function and any changes in each body system.

A. diaphoresis B. hypoxia C. hemoptysis D. Tachypnea

Correct Answer is A

Explanation

A. Diaphoresis – Diaphoresis refers to excessive sweating, which can be caused by fever, infections, hyperthyroidism, or stress.

B. Hypoxia – Hypoxia is a condition where tissues do not receive adequate oxygen, leading to symptoms like confusion and cyanosis.

C. Hemoptysis – Hemoptysis is the coughing up of blood, commonly seen in tuberculosis, lung cancer, or pulmonary embolism.

D. Tachypnea – Tachypnea is rapid breathing, which may occur due to fever, anxiety, or metabolic acidosis but does not involve excessive sweating.

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The patient has been found to have edema of the lower extremities. The nurse is assessing whether or not it is pitting and to what degree. After pressing the skin against a bony prominence for 5 seconds, the nurse identifies 4+ pitting edema because the rebound time is:

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Naxlex Comprehensive Predictor Exams

The nurse uses a systematic method for collecting data on all body systems including normal functioning and any noted changes. This system is:

Correct Answer is D

Explanation

The profuse secretion of sweat associated with an elevated body temperature, certain disease conditions, physical exertion, exposure to heat and mental or emotional stress is termed:

Correct Answer is A

Explanation

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Adventitious breath sounds that have a whistling or sighing sound due to narrowing of the lumen of a respiratory passage are termed:

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When performing the nursing physical assessment, the nurse uses head-to-toe organization. When using this method, the nurse begins with a:

The protective response of body tissues to irritation, injury or pathogens is:

Redness or inflammation of the skin or mucous membranes resulting from dilation and congestion of superficial capillaries is termed:

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