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.
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Correct Answer is C
Explanation
A. Response to verbal stimuli does not directly assess the function of cranial nerves III, IV, and VI.
B. Affect, feelings, or emotions are related to the assessment of other neurological functions and do not evaluate the ocular cranial nerves specifically.
C. Eye movements are the primary function of cranial nerves III (oculomotor), IV (trochlear), and VI (abducens), which control eye movement and provide essential information about their function.
D. Insight, judgment, and planning relate more to cognitive function and do not directly assess the function of the cranial nerves in question.
Correct Answer is B
Explanation
A. A pulse oximeter is used to measure oxygen saturation and is not relevant to cochlear dysfunction.
B. A hearing aid is appropriate for someone with cochlear dysfunction as it can help amplify sound and improve hearing, indicating the client is adapting to the hearing loss.
C. Eyeglasses are used for vision problems and do not relate to the function of the cochlear division of the vestibulocochlear nerve.
D. A bath thermometer is used to measure water temperature and is not relevant to auditory issues.