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 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.
Correct Answer is A
Explanation
A. To determine the heart rate from a rhythm strip, you can count the number of R-R intervals in a set time frame (typically 6 seconds) and multiply by 10 to convert to beats per minute. If the rhythm is regular, you can also use the 300 method by dividing 300 by the number of large squares between R waves. In this case, the rate is calculated to be 90 beats per minute.
B. A heart rate of 110 beats per minute would be classified as tachycardia and is not supported by the observed intervals.
C. A heart rate of 73 beats per minute would be a normal resting heart rate but does not match the calculation from the rhythm strip.
D. A heart rate of 50 beats per minute would indicate bradycardia, which is not reflected in this rhythm strip.