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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?

A.

Severe pitting, very swollen leg and indentation that lasts for a long time, 8 mm deep

B.

Slight indentation, with no perceptible swelling of the leg. 2 mm deep

C.

Moderate pitting, with indentation that subsides rapidly, 4 mm deep

D.

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.


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Correct Answer is B

Explanation

A. Observing for facial symmetry assesses cranial nerves VII (facial nerve), not cranial nerve III.

B. Cranial nerve III (oculomotor nerve) is responsible for eye movement and pupillary response, making checking the pupillary response to light the correct action.

C. Testing visual acuity primarily assesses cranial nerve II (optic nerve), not cranial nerve III.

D. Eliciting the gag reflex is associated with cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve III.

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.

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