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","B"]
Explanation
A. Bronchovesicular sounds are normal lung sounds that are typically heard over the mainstem bronchi and are expected during auscultation.
B. Bronchial sounds are also normal and are typically heard over the trachea; they are expected lung sounds.
C. Dullness is not a lung sound but rather a descriptor of percussion notes, typically indicating fluid or solid mass in the lungs.
D. Flatness is also not a normal lung sound but refers to a percussion note that can suggest the presence of fluid or a solid mass.
Correct Answer is D
Explanation
A. A pustule is a small elevation of the skin that contains pus, typically smaller than 0.5 cm.
B. A macule is a flat, discolored area of skin that is less than 0.5 cm in diameter, so it does not fit the description of elevated lesions larger than 0.5 cm.
C. A papule is an elevated, solid lesion that is less than 0.5 cm in diameter; lesions larger than this would not be classified as papules.
D. A patch is defined as a flat, non-palpable lesion larger than 0.5 cm, and psoriasis can present as patches. Thus, the lesions described fit this classification.