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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).

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A. Provides care that is based on meanings generated by predetermined criteria. B. Provides care that is based on the priorities of the hospital unit workflow. C. Provides care that is the same as the values of the professional health care system D. Provides care that makes the nurse the leader in determining what is needed. E. Provides care that honors the client's differences and perspectives.

Correct Answer is E

Explanation

A. Providing care based on predetermined criteria may overlook individual client needs and cultural nuances.

B. Prioritizing hospital unit workflow may not align with the individual needs of clients.

C. Care aligned with professional healthcare values may not address the specific cultural values and preferences of diverse clients.

D. This approach may dismiss the client's autonomy and unique cultural context.

E. Honoring the client's differences and perspectives indicates a commitment to culturally responsive care, recognizing and respecting diverse backgrounds.

A. Hyperresonance B. Bubbling C. Tympany D. Dullness E. Resonance

Correct Answer is D

Explanation

A. Hyperresonance is often heard in cases of pneumothorax or emphysema, not pneumonia.

B. Bubbling is not a percussed sound but rather a description of breath sounds or fluid.

C. Tympany is typically heard over hollow organs like the stomach and is not expected in lung assessment.

D. Dullness over lung tissue indicates fluid or consolidation, as seen in pneumonia.

E. Resonance is normal over healthy lung tissue but would not be expected over areas of consolidation.

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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?

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Correct Answer is E

Explanation

Correct Answer is D

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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?

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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?