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 C

Explanation

A. Causative. – Causative factors directly lead to a disease (e.g., bacteria causing an infection), while risk factors increase the likelihood of developing a disease.

B. Etiological. – Etiology refers to the study of disease causes, but risk factors contribute to disease development rather than being the direct cause.

C. Risk. – Risk factors increase an individual's susceptibility to disease. Examples include smoking (lifestyle), genetic predisposition, and aging.

D. Hazardous. – Hazardous factors refer to dangers or unsafe conditions (e.g., environmental hazards) rather than biological predispositions to disease.

A. assess for level of consciousness and orientation B. check for pitting edema C. assess the skin D. listen to lung sounds

Correct Answer is A

Explanation

A. Assess for level of consciousness and orientation – Level of consciousness (LOC) and orientation are crucial in evaluating neurological status, overall health, and potential signs of deterioration. This assessment provides immediate information about the patient’s cognitive function and responsiveness.

B. Check for pitting edema – Assessing for pitting edema is important but is not the first priority unless the patient has signs of fluid overload or heart failure.

C. Assess the skin – Skin assessment is essential but should be performed after ensuring the patient's neurological stability.

D. Listen to lung sounds – While lung auscultation is an important part of the assessment, it follows after assessing consciousness and orientation.

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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

There are four categories of factors that increase the individual's vulnerability to developing a disease. These categories are genetic, physiological, age and lifestyle. These factors are called:

Correct Answer is C

Explanation

The nurse has been assigned to care for a 62 year-old man. After introducing herself to the patient and explaining that she will be performing a nursing assessment, what is the first area to be assessed after taking vital signs?

Correct Answer is A

Explanation

Auscultation of the heart sounds will result in a lubb-dupp sound when using the bell and the diaphragm of the stethoscope. The lub part of the sound is caused by the:

An abnormally rapid heart rate above 100 beats per minute is called:

The nurse is collecting data during an initial assessment. The patient tells the nurse, "i have a tremendous headache and my stomach is upset." These findings are called:

When a disease results in a structural change in an organ that interferes with its functioning, this is a/an:

The nurse is obtaining a history of the patient's present illness. The PQRST system is being used for the interview. In this system the R is:

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:

An abnormal accumulation of fluid in the interstitial spaces is described as:

Any disturbance of the structure or function of the body is a pathological condition. This condition is termed a/an: