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
Explanation
A. Vitamin D deficiency is a modifiable risk factor because it can be addressed through dietary changes, supplements, and increased sun exposure.
B. A small-boned, thin frame is considered a nonmodifiable risk factor as it is a genetic characteristic that cannot be changed.
C. A personal history of fractures is also a nonmodifiable risk factor, as past fractures indicate an increased risk for future fractures and cannot be altered.
D. Age is a nonmodifiable risk factor, as it is an intrinsic characteristic that cannot be changed.
Correct Answer is A
Explanation
A. Having the child bend at the waist allows the nurse to observe the spine for any abnormal curvature indicative of scoliosis, such as uneven shoulders or a rib hump.
B. Measuring the distance between the knees and the ankles is not a technique used to screen for scoliosis; it is more related to assessing leg length discrepancies.
C. Measuring the length of each leg does not assess for scoliosis but is more relevant for evaluating leg length inequalities.
D. Asking the child to walk across the room is useful for assessing gait and balance but does not directly assess for scoliosis.