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. edema B. ecchymosis C. pallor D. Erythematosis

Correct Answer is A

Explanation

A. Edema. – Edema refers to fluid buildup in the interstitial spaces, leading to swelling in tissues. It can be caused by conditions such as heart failure, kidney disease, or inflammation.

B. Ecchymosis. – Ecchymosis refers to bruising caused by blood leakage into subcutaneous tissue, not fluid accumulation.

C. Pallor. – Pallor describes an abnormal pale appearance of the skin, often due to anemia or shock, rather than fluid accumulation.

D. Erythematosis. – Erythematosis is associated with redness and inflammation, not fluid retention.

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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

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

Correct Answer is A

Explanation

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