Author Question: A nurse is examining a client with cirrhosis of the liver and notes the presence of edema. The nurse ... (Read 59 times)

altibaby · **on:** Jul 22, 2018

A nurse is examining a client with cirrhosis of the liver and notes the presence of edema. The nurse determines that the indentation remains for several seconds and the skin swelling is obvious on inspection.

How should the nurse quantify the severity of the finding? A) 1+ pitting edema
B) 2+ pitting edema
C) 3+ pitting edema
D) 5+ brawny edema

Question 2

A hospital client with impaired mobility has rung his call bell for assistance with transferring from his bed to a commode in order to have a bowel movement. The urge to defecate is triggered by

A) Pressure on the peritoneal membrane
B) Friction of stool against the sigmoid colon
C) Distention of the rectum by stool
D) Osmotic changes in the lower bowel

pratush dev · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

C
Feedback:
The nurse should quantify the finding as 3+ pitting edema, since the indentation remains for several seconds and a skin swelling is obvious by general inspection. In case of 1+ pitting edema, there is a slight indentation (2 mm) with normal contours and the associated interstitial fluid volume is 30 above normal. 2+ pitting edema indicates that the indentation is deeper after pressing (4 mm) and lasts longer than a 1+, with fairly normal contours. In the case of 5+ brawny edema, there is no pitting; tissue palpates as firm or hard, and the skin surface appears shiny, warm, and moist.

Answer to Question 2

C
Feedback:
The increased peristalsis of the gastrocolic reflex usually precedes defecation. Its accelerated wavelike movements, sometimes perceived as slight abdominal cramping, propel stool forward, packing it within the rectum. As the rectum distends, the person feels the urge to defecate. The urge to defecate does not result from friction on the colon, pressure against the peritoneum, or osmotic changes.