Difficulty: Medium
Average Score: 89%
Simulated
A client drove himself to the urgent care center for, "Legs that look like balloons and difficulty walking." The nurse assesses 4+ edema of both legs based upon which finding?
Correct answer
A
Rationale
The correct answer is A because the description of "very deep pitting indentation of legs that lasts several minutes" indicates severe edema. This level of pitting edema is associated with a significant accumulation of fluid in the tissues, causing the legs to swell like balloons. The nurse should be concerned about potential serious underlying conditions such as heart failure, kidney disease, or venous insufficiency.
Choice B is incorrect as deep pitting that lasts only a few minutes is less severe than the described scenario. Choice C is incorrect because mild pitting with no perceptible swelling does not match the client's presentation. Choice D is incorrect as moderate pitting that subsides rapidly is less severe than what the client is experiencing.
Choice B is incorrect as deep pitting that lasts only a few minutes is less severe than the described scenario. Choice C is incorrect because mild pitting with no perceptible swelling does not match the client's presentation. Choice D is incorrect as moderate pitting that subsides rapidly is less severe than what the client is experiencing.