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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is ["B","C","E"]
Explanation
A. The diaphragm of the stethoscope is used for high-pitched sounds, such as lung and normal heart sounds, not low-pitched sounds.
B. The binaural (earpieces) should fit snugly in the ears to ensure proper sound transmission and clarity.
C. Short tubing provides more accurate sounds by minimizing sound distortion, making it ideal for clinical use.
D. The bell of the stethoscope is used for low-pitched sounds, such as heart murmurs, not high-pitched sounds.
E. The stethoscope works by blocking out environmental sounds to help the user focus on internal body sounds.
Correct Answer is D
Explanation
A. Bradypnea (slow breathing) may occur in various conditions but is not a defining characteristic of cyanosis.
B. A pale reddish color in the skin is not consistent with cyanosis, which indicates a lack of oxygen in the blood.
C. Somnolence (drowsiness) may be present in some patients, but it is not a specific finding related to cyanosis.
D. Mottled blue color in the skin is a classic sign of cyanosis, indicating inadequate oxygenation of the blood, especially in the extremities or areas with poor circulation.