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. +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.
Correct Answer is D
Explanation
A. Elevated blood pressure is not an indication of dehydration; dehydration is more likely to cause a drop in blood pressure due to decreased blood volume.
B. Dehydration typically does not cause a low body temperature; instead, it can lead to an elevated temperature as the body conserves water.
C. Jugular vein distention is associated with fluid overload or heart failure, not dehydration.
D. Skin tenting, where the skin remains elevated after being pinched, is a classic sign of dehydration due to reduced skin elasticity.