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).
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Correct Answer is B
Explanation
A. Venous insufficiency typically presents with swelling and pain that worsens with prolonged standing, not with exercise.
B. Claudication is the correct term, as it describes pain due to decreased blood flow to the muscles during exercise, often relieved by rest, which matches the patient's symptoms.
C. Muscle cramps may cause pain but are usually not consistently triggered by activity and relieved by rest.
D. Deep vein thrombosis would typically present with pain, swelling, warmth, and redness rather than exercise-induced pain relieved by rest.
E. Bruit from turbulent blood flow is an audible sound over an artery and not directly related to the type of pain described.
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.