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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?

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

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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A. Assess visual acuity B. Elicit gag reflex C. Checking for pupillary response to light D. Observing for facial symmetry

Correct Answer is A

Explanation

A. Assessing visual acuity directly tests cranial nerve II (the optic nerve), which is responsible for vision.

B. Eliciting the gag reflex tests cranial nerves IX (glossopharyngeal) and X (vagus), not cranial nerve II.

C. Checking for pupillary response to light primarily assesses the function of cranial nerve II but is more associated with cranial nerve III (oculomotor) since it involves the constriction of the pupil. While relevant, it is not the best standalone action for assessing cranial nerve II specifically.

D. Observing for facial symmetry is associated with cranial nerve VII (facial nerve), not cranial nerve II.

A. The client has complete bilateral paralysis of the arms and legs. B. The client has lost the ability to move the right arm but is able to walk independently. C. The client has lost the ability to move the right arm but is able to walk independently. D. The client has weakness on the right side of the face and tongue. E. The client has lost the ability to ambulate independently but is able to feed and bathe herself or himself without assistance. F. The client has weakness on the right side of the body.

Correct Answer is ["D","F"]

Explanation

A. This statement indicates complete paralysis of both sides, which does not apply to hemiparesis, where one side is affected.

B. While this could describe some patients, it does not accurately represent "complete" right-sided hemiparesis.

C. This option is a repeat and also does not accurately reflect complete right-sided hemiparesis.

D. Weakness on the right side of the face and tongue is consistent with right-sided hemiparesis, as the stroke may affect motor control in those areas.

E. This describes a client who is less severely affected and may not apply to someone with complete right-sided hemiparesis.

F. Weakness on the right side of the body is a direct characteristic of right-sided hemiparesis.

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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?

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Correct Answer is A

Explanation

Correct Answer is ["D","F"]

Explanation

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Take full exam for free 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?

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A nurse is assessing a client's cranial nerves as part of a neurological examination. Which action should the nurse take to assess cranial nerve II?

Correct Answer is A

Explanation

The nurse is assigned to care for a client with complete right-sided hemiparesis [weakness] from a stroke (brain attack). admitting diagnosis cerebrovascular attack Right-sided hemiparesis Which characteristics are associated with this condition? Select 2 that apply.

Correct Answer is ["D","F"]

Explanation

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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?