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 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.