A nurse is assessing a client with a history of heart failure who presents with severe edema in the lower extremities. The nurse would document the presence of +4 pitting edema after noting which finding?
Severe pitting, very swollen leg and indentation that lasts for a long time, 8 mm deep
Slight indentation, with no perceptible swelling of the leg. 2 mm deep
Moderate pitting, with indentation that subsides rapidly, 4 mm deep
Deep pitting, swollen leg, and indentation that remains for a short time, 6 mm deep
The Correct Answer is A
A. +4 pitting edema is characterized by severe pitting that creates a deep indentation (greater than 8 mm) that remains for a prolonged period. This description matches the findings in option
B. This describes +1 pitting edema, which is not consistent with +4 edema.
C. This option describes +2 or +3 pitting edema, as the indentation subsides rapidly, which does not align with +4.
D. Although this describes deep pitting, the depth is less than 8 mm, which is not consistent with +4 edema.
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Correct Answer is A
Explanation
A. The bell of the stethoscope is best used to listen for low-pitched sounds, including some types of murmurs, and can help assess the quality and intensity of a cardiac murmur.
B. While palpation can provide some information about the heart's function (such as thrills), it is not the primary method for assessing the quality of a murmur.
C. A Doppler ultrasound device is used for measuring blood flow and can help in assessing murmurs but does not provide the quality assessment needed for characterizing a murmur.
D. Percussion is not typically used to evaluate murmurs; it is more useful for assessing the size and borders of organs.
Correct Answer is A
Explanation
A. Cranial nerve VII (facial nerve) is not primarily responsible for hearing; however, it does have some sensory function in the ear region. The primary cranial nerve responsible for hearing is cranial nerve VIII (vestibulocochlear), which is not listed among the options.
B. Cranial nerve X (vagus nerve) is primarily involved in autonomic functions and does not directly relate to hearing.
C. Cranial nerve I (olfactory nerve) is responsible for the sense of smell.
D. Cranial nerve II (optic nerve) is responsible for vision.