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 ["C","D","E"]
Explanation
A. Numbness in the right arm is not a risk factor for skin cancer; it is more related to neurological issues or circulation problems.
B. While working in a beauty parlor may involve exposure to certain chemicals, it is not a significant risk factor for skin cancer compared to other options.
C. A client with a fair skin complexion and blue eyes has a higher risk for skin cancer due to lower melanin levels, making them more susceptible to UV damage.
D. Smoking is primarily associated with lung cancer; however, it can also contribute to skin damage and increased risk for skin cancer, particularly squamous cell carcinoma.
E. A roofer who spends a lot of time outdoors and experiences blistering sunburns is at significant risk for skin cancer due to excessive UV exposure and history of severe sunburns.
Correct Answer is D
Explanation
A. In the anterior chest assessment, auscultation usually follows inspection and is typically done before percussion.
B. In the neck assessment, the nurse may inspect and then auscultate (e.g., carotid arteries) before palpation.
C. In the heart assessment, auscultation follows inspection but may not involve percussion.
D. In the abdomen, the correct order is to inspect, auscultate, and then percuss to assess bowel sounds effectively before creating additional disturbances with percussion.