A nurse caring for a nine-year-old notices some swelling in the child's ankles. The nurse presses against the ankle bone for five seconds, then releases the pressure, noticing a markedly slow disappearance of the indentation

Question

Based on these physical findings, the nurse would be most concerned with assessing: 1. Skin integrity, especially in the lower extremities.
2. Level of consciousness.
3. Urine output.
4. Range of motion and ankle mobility.

Answer 1

3
Rationale 1: While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.
Rationale 2: While there may be an underlying condition causing the edema that could later result in changes in level of consciousness, assessing level of consciousness based on these findings is unlikely to elicit the cause of the child's edema.
Rationale 3: Dependent, pitting edema, especially in the lower extremities, can be a symptom of kidney and cardiac disorders. Decreases in urine output also can indicate compromise in the renal and cardiac systems.
Rationale 4: While ankle edema could lead to both decreased ankle mobility and compromise in skin integrity, diagnosing and treating the underlying cause of the edema is most important.
Global Rationale: