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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 D

Explanation

A. Petechiae are small, pinpoint hemorrhages and are considered objective data that can be observed and documented by the nurse.

B. Blood pressure is a vital sign and objective data that can be measured using a sphygmomanometer.

C. Cyanosis is a physical sign indicating low oxygenation in the blood and is objective data that can be observed.

D. Nausea is a subjective symptom reported by the client, reflecting their internal experience and cannot be measured or observed directly.

Correct Answer is A

Explanation

A. The carotid pulse should not be assessed bilaterally at the same time, as simultaneous palpation can lead to a decrease in heart rate or cause syncope due to stimulation of the carotid sinus.

B. The radial pulse can be assessed bilaterally without risk.

C. The brachial pulse can also be assessed bilaterally without concern.

D. The femoral pulse is typically assessed one side at a time, but there is no risk in palpating both femoral arteries simultaneously as there is with the carotid.

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