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","C"]
Explanation
A. Increase daily exercise: Regular physical activity helps stimulate bowel movements and can relieve constipation.
B. Be sure to take good care of your teeth: While dental health is important, it is not directly related to constipation management.
C. Incorporate more fresh fruits and vegetables in your daily intake: These foods are high in fiber, which helps to soften stool and promote regularity.
D. Avoid drinking hot liquids: This is not a standard recommendation for managing constipation; warm liquids can sometimes aid in bowel movements.
E. Increase intake of low fiber foods: This would likely worsen constipation, as low-fiber diets can contribute to harder stools.
Correct Answer is D
Explanation
A. Flexion refers to bending the joint, which does not apply when turning the palm down.
B. Supination is the movement of turning the palm up, which is the opposite of what is being tested here.
C. Rotation refers to the circular movement around a central point, but it does not specifically describe the action of turning the palm down.
D. Pronation is the movement of turning the palm down, which is exactly what the client is doing when asked to perform this maneuver.