Take full exam for free

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?

Answer and Explanation

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

Take full exam free

View Related questions

A. Leave B. Leverage C. Listen D. Look E. Liken

Correct Answer is C

Explanation

A. "Leave" is not a part of the LEARN mnemonic.

B. "Leverage" is also not included in the LEARN mnemonic.

C. "Listen" is the correct answer; it encourages active listening to understand the client’s cultural needs and perspectives.

D. While "Look" may imply observation, it is not a component of the LEARN mnemonic.

E. "Liken" is not part of the LEARN mnemonic and is not relevant here.

A. S1 and S2 heard with diaphragm of stethoscope B. A blowing sound heard over the mitral area with the bell of the stethoscope C. Apical pulse palpated at 5th intercostal space, midclavicular line D. Absent sound over carotid arteries with bell of the stethoscope

Correct Answer is B

Explanation

A. S1 and S2 heard with the diaphragm of the stethoscope is a normal finding, as these are the expected heart sounds.

B. A blowing sound heard over the mitral area with the bell of the stethoscope suggests a possible murmur, which could indicate valvular abnormalities and is considered abnormal.

C. Apical pulse palpated at the 5th intercostal space, midclavicular line is normal and expected in adults.

D. Absence of sound over carotid arteries with the bell of the stethoscope indicates no bruits and is considered normal.

Take full exam for free

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?

Free Nursing Test Bank

Correct Answer is C

Explanation

Correct Answer is B

Explanation

Quick Links

Resources

Take full exam for free 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?

Free Nursing Test Bank

A nurse is performing a cultural assessment using the LEARN mnemonic for communication. Which area will the nurse assess for the "L" portion of the mnemonic?

Correct Answer is C

Explanation

The nurse is performing a focused cardiovascular assessment on a 70-year-old client. What finding would be considered abnormal? No palpable vibration felt over the precordium (chest wall)

Correct Answer is B

Explanation

A postoperative client with a tracheostomy tube in place suddenly begins have noisy, bubbly sounding respirations. What action should the nurse take first?

The nurse is observing the lung auscultation technique of a student nurse. What is the correct method to use when progressing from one auscultatory site to another?

Which of the following scenarios gives the most absolute confirmation client learning has taken place? Select all that apply.

What subjective data should the nurse obtain about a client's cardiac status? Select all that apply.

A client with pneumonia is admitted to the medical/surgical floor. Which activity is most important for the nurse to include in the plan of care?

When teaching a health promotion class at a retirement home for individuals 65 or greater, which information would the nurse include about ways to decrease the spread of respiratory infections?

Which nonpharmacologic pain treatment should the nurse avoid using in an older adult who shows signs of confusion?

The nurse is assessing a newly admitted client for heart failure. What findings would the nurse expect to find during the assessment? Select all that apply.

Quick Links

Resources

Take full exam for free

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?