How would the nurse document mild, slight pitting edema of the ankles, where there can be no perceptible swelling seen, the indentation depth will be less than 2mm, and the indentation will disappear in less than 10 seconds?
3+
1+
2+
+0
4+
The Correct Answer is B
A. 3+ edema indicates moderate pitting (indentation depth of 5-7 mm and lasting 10-20 seconds).
B. 1+ edema is classified as slight pitting (indentation depth less than 2 mm that disappears rapidly, typically in less than 10 seconds), making this the correct documentation.
C. 2+ edema indicates moderate pitting (indentation depth of 3-4 mm that lasts up to 15 seconds).
D. +0 indicates no edema present at all.
E. 4+ edema indicates severe pitting (indentation depth of greater than 8 mm and lasting more than 20 seconds).
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 A
Explanation
A. In peripheral arterial insufficiency, blood flow is reduced, leading to cooler skin temperatures, especially in the affected extremity.
B. Nail appearance may be unhealthy due to poor perfusion; nails may become thickened or grow slowly.
C. Skin is typically cool and may be dry, not warm, indicating reduced blood flow.
D. A pulse of 2+ is within normal range; however, pulses may be diminished or absent in cases of significant arterial insufficiency.
E. The leg typically does not appear swollen; rather, it may show signs of atrophy or hair loss due to inadequate blood supply.
Correct Answer is C
Explanation
A. A barrel chest is a common finding in patients with emphysema due to lung hyperinflation but is not immediately life-threatening.
B. A respiratory rate of 22 per minute indicates mild tachypnea, which can be expected in patients with COPD, but is not the most alarming sign.
C. Oral cyanosis is a concerning sign that indicates inadequate oxygenation and can suggest severe respiratory distress or failure, necessitating immediate intervention.
D. Decreased lung sounds on expiration can occur in emphysema but is not as critical as the presence of cyanosis.
E. Pursed-lip expiration is a compensatory mechanism used by patients with COPD to improve breathing efficiency; it is generally a positive adaptive strategy.