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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. Gynecomastia refers to breast tissue enlargement in males and does not typically relate to the menstrual cycle.

B. Cyclic pain refers to breast pain that is linked to the menstrual cycle, commonly occurring before menstruation and subsiding during or after menstruation.

C. Mammary pain is a broader term that may refer to any breast pain, but it does not specify the cyclical nature related to menstruation.

D. Noncyclic pain refers to breast pain not related to the menstrual cycle and does not follow the described pattern.

Correct Answer is B

Explanation

A. Assessing the pedal pulses does not provide relevant information about the irregularity of the radial pulse.

B. Assessing the apical pulse for a full minute is appropriate in this situation, as it provides a more accurate measurement of the heart rate and rhythm, especially when the radial pulse is irregular.

C. Assessing the popliteal pulses with a Doppler device is not necessary and does not directly address the irregular radial pulse.

D. While a pulse oximeter can provide information about oxygen saturation, it does not assess heart rate or rhythm.

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