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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. A client demonstrates how to inject insulin into the abdomen B. A client attends a course on exercise techniques C. A client watches the nurse apply a dressing D. A client lists food choices that are considered part of a healthy diet E. A client nods when told how to take the blood pressure medication

Correct Answer is ["A","D"]

Explanation

A. Demonstrating an insulin injection shows hands-on learning and mastery of the skill.

B. Attending a course does not confirm comprehension or skill.

C. Watching a nurse apply a dressing does not guarantee learning; active participation is necessary.

D. Listing healthy food choices indicates understanding of dietary education.

E. Nodding does not confirm learning; it may only indicate acknowledgment.

A. a sign of congestive heart failure B. a normal finding in a healthy adult. C. seen in patients with kyphosis. D. indicative of a pneumothorax. E. an expected finding in a patient with a barrel chest.

Correct Answer is C

Explanation

A. CVA tenderness is associated with renal issues, not directly with congestive heart failure.

B. A CVA angle of 160 degrees is abnormal; a normal angle is closer to 90 degrees, indicating potential issues.

C. A greater CVA angle can be observed in patients with kyphosis, where the spine curves excessively, affecting rib positioning.

D. A pneumothorax typically results in reduced breath sounds and tracheal deviation, not specifically linked to CVA angle changes.

E. A barrel chest results in an increased AP diameter, not typically associated with CVA angle changes.

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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 ["A","D"]

Explanation

Correct Answer is C

Explanation

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

Correct Answer is ["A","D"]

Explanation

When performing a respiratory assessment on a patient, the nurse notices a costal vertebral angle (CVA) of approximately 160 degrees. How would finding?

Correct Answer is C

Explanation

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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?