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. While posterior to anterior comparisons are used, they do not encompass the entire technique for auscultation.
B. Side-to-side comparison is the correct method as it allows for immediate assessment of differences between lung fields and helps to identify abnormal sounds effectively.
C. Interspace-by-interspace comparison is not a commonly recognized term for this method and can lead to confusion in technique.
D. Proximal to distal comparison is not specific to lung auscultation and does not effectively apply to lung assessment.
E. Top-to-bottom comparison may miss abnormalities in a specific region of the lungs; side-to-side is preferred.
Correct Answer is B
Explanation
A. Poor electrical impulse conduction may lead to arrhythmias but does not cause a murmur.
B. A heart murmur is caused by turbulent blood flow, often through narrowed or leaking valves, creating an abnormal heart sound.
C. Left ventricular enlargement can contribute to other cardiac issues but does not directly cause murmurs.
D. Weak atrial contractions may lead to decreased cardiac output but not necessarily to a murmur.
E. While hypertension can affect the heart, it is not the direct cause of a murmur.