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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. The nurse will simultaneously touch the client in the same area on both sides of the body, and the client will identify where the touch occurred. B. The nurse will briefly touch the client, and the client will need to identify where the touch occurred. C. Client will close their eyes and identify what number the nurse writes in the palm of the client's hand with a blunt-ended object. D. The client is to identify the numbers of points felt when the nurse touches the client with the ends of two applicators at the same time.

Correct Answer is C

Explanation

A. This description relates more to a sensory discrimination test, not graphesthesia.

B. This option does not accurately describe the graphesthesia test, which involves identifying shapes or numbers rather than just touch location.

C. In the graphesthesia test, the client closes their eyes while the nurse uses a blunt object to write a number or shape in the client's palm, and the client must identify what was written. This assesses the ability to recognize letters or numbers drawn on the skin.

D. This option describes a two-point discrimination test rather than graphesthesia, which focuses on identifying drawn shapes or numbers.

A. Oatmeal B. Apples C. Chocolate D. Nonfat milk

Correct Answer is C

Explanation

A. Oatmeal is generally considered a good food for individuals with GERD as it can help absorb stomach acid.

B. Apples are typically a safe fruit for GERD sufferers.

C. Chocolate can relax the lower esophageal sphincter and may worsen GERD symptoms, so it should be avoided.

D. Nonfat milk is usually tolerated better than full-fat dairy products and may help soothe the stomach.

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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 C

Explanation

Correct Answer is C

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 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?