Take full exam for free

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

Answer and Explanation

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.

Free Nursing Test Bank

Take full exam free

View Related questions

A. Obesity B. Race C. History of smoking D. History of hypertension

Correct Answer is B

Explanation

A. Obesity is a modifiable risk factor, as it can be addressed through lifestyle changes such as diet and exercise.

B. Race is a nonmodifiable risk factor; certain races may have a higher risk of stroke due to genetic and environmental factors.

C. History of smoking is a modifiable risk factor because individuals can choose to quit smoking to reduce their risk of stroke.

D. History of hypertension is also a modifiable risk factor; while having high blood pressure increases the risk of stroke, it can be managed with lifestyle changes and medications.

A. The client has complete bilateral paralysis of the arms and legs. B. The client has lost the ability to move the right arm but is able to walk independently. C. The client has lost the ability to move the right arm but is able to walk independently. D. The client has weakness on the right side of the face and tongue. E. The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance. F. The client has weakness on the right side of the body.

Correct Answer is ["D","F"]

Explanation

A. This statement indicates complete paralysis of both sides, which does not apply to hemiparesis, where one side is affected.

B. While this could describe some patients, it does not accurately represent "complete" right-sided hemiparesis.

C. This option is a repeat and also does not accurately reflect complete right-sided hemiparesis.

D. Weakness on the right side of the face and tongue is consistent with right-sided hemiparesis, as the stroke may affect motor control in those areas.

E. This describes a client who is less severely affected and may not apply to someone with complete right-sided hemiparesis.

F. Weakness on the right side of the body is a direct characteristic of right-sided hemiparesis.

Take full exam for free

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?

Free Nursing Test Bank

Correct Answer is B

Explanation

Correct Answer is ["D","F"]

Explanation

Quick Links

Resources

Take full exam for free 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?

Free Nursing Test Bank

A nurse is teaching about the risk factors of developing a stroke with a group of older adult clients. Which nonmodifiable risk factors should the nurse include in the teaching?

Correct Answer is B

Explanation

The nurse is assigned to care for a client with complete right-sided hemiparesis [weakness] from a stroke (brain attack). admitting diagnosis cerebrovascular attack Right-sided hemiparesis Which characteristics are associated with this condition? Select 2 that apply.

Correct Answer is ["D","F"]

Explanation

The nurse is performing a neurological assessment on a client and is assessing the function of cranial nerves III, IV, and VI. Assessment of which aspect of function will yield the best information about these cranial nerves?

Which disorder is depicted in the image below?

While performing an abdominal assessment on a patient, the nurse notes an abdomen shape similar to the rounded abdomen only greater. This contour is anticipated in pregnancy and seen in adults with ascites and obesity. What term should the nurse use to document this finding?

Providing a safe and comfortable environment, applying critical thinking, and identifying cues presented by the patient is

Which shape should the nurse expect a client's chest to be when assessing a client who has COPD?

A client has dysfunction of the cochlear division of the vestibulocochlear nerve (cranial nerve VIII). The nurse should determine that the client is adequately adapting to this problem if he or she states a plan to obtain which item?

When completing a neurological assessment, which cranial nerves are tested within the mouth?

During which part of a comprehensive physical assessment would the nurse auscultate after inspecting but before percussing?

Quick Links

Resources

Take full exam for free

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?