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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?

A.

3+

B.

1+

C.

2+

D.

+0

E.

4+

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

Explanation

A. A febrile state indicates that the client may not be in an optimal condition to learn effectively, so postponing the session is appropriate.

B. Mild anxiety may not require postponement, as it can be addressed during teaching.

C. Nausea can significantly impair concentration and engagement in learning, warranting a delay.

D. A pain level of 8 out of 10 suggests significant discomfort, making it challenging for the client to focus on learning.

E. Asking questions indicates engagement and a readiness to learn, so this does not warrant postponing the session.

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

Explanation

A. S4 is often considered a normal finding in older adults due to decreased ventricular compliance.

B. While it can be non-pathologic, it is more commonly associated with underlying conditions such as hypertension or heart failure.

C. The statement about being heard just after S2 is incorrect; S4 can be heard in various populations, particularly older adults.

D. An S4 sound is associated with a stiff or hypertrophied ventricle, not a dilated ventricle.

E. An S4 sound is not typically an expected finding in children; it is more common in older adults.

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