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 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.
Correct Answer is C
Explanation
A. A barrel chest is a common finding in patients with emphysema due to lung hyperinflation but is not immediately life-threatening.
B. A respiratory rate of 22 per minute indicates mild tachypnea, which can be expected in patients with COPD, but is not the most alarming sign.
C. Oral cyanosis is a concerning sign that indicates inadequate oxygenation and can suggest severe respiratory distress or failure, necessitating immediate intervention.
D. Decreased lung sounds on expiration can occur in emphysema but is not as critical as the presence of cyanosis.
E. Pursed-lip expiration is a compensatory mechanism used by patients with COPD to improve breathing efficiency; it is generally a positive adaptive strategy.