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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 A

Explanation

A. Respiratory acidosis: The pH is low (indicating acidosis), and the Paco₂ is elevated, which signifies that carbon dioxide retention is causing the acidosis. This pattern indicates respiratory acidosis, as the elevated HCO₃ suggests a compensatory response.

B. Respiratory alkalosis: Respiratory alkalosis would show a high pH with a low Paco₂. This is not consistent with the client’s lab results.

C. Metabolic acidosis: Metabolic acidosis would show a low pH with a low HCO₃. In this case, the HCO₃ is slightly elevated, ruling out metabolic acidosis.

D. Metabolic alkalosis: Metabolic alkalosis would show a high pH with an elevated HCO₃, which does not match the client’s results.

Correct Answer is D

Explanation

A. Checking pupillary response to light assesses cranial nerve II (optic nerve).

B. Observing for facial symmetry primarily assesses cranial nerves VII (facial nerve) and possibly V (trigeminal nerve).

C. Testing for sense of smell assesses cranial nerve I (olfactory nerve).

D. Eliciting the gag reflex assesses cranial nerve IX (glossopharyngeal nerve) and also cranial nerve X (vagus nerve), making it the correct action to assess cranial nerve IX.

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