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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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View Related questions

Correct Answer is C

Explanation

A. This is a dark vertical line that can appear on the abdomen during pregnancy, typically extending from the pubic area to the navel, which is not what is depicted in the image of a Mongolian Spot.

B. A chronic skin condition that results in red, itchy, scaly patches; this does not match the appearance of a Mongolian Spot.

C. This is the correct answer as it refers to a blue-gray pigmentation commonly found on the backs and buttocks of infants, particularly in individuals of Asian or African descent.

D. These are small, white cysts that can appear on the skin, typically on the face, and are not consistent with the description of a Mongolian Spot.

Correct Answer is A

Explanation

A. Having the child bend at the waist allows the nurse to observe the spine for any abnormal curvature indicative of scoliosis, such as uneven shoulders or a rib hump.

B. Measuring the distance between the knees and the ankles is not a technique used to screen for scoliosis; it is more related to assessing leg length discrepancies.

C. Measuring the length of each leg does not assess for scoliosis but is more relevant for evaluating leg length inequalities.

D. Asking the child to walk across the room is useful for assessing gait and balance but does not directly assess for scoliosis.

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