A nurse caring for a 9-year-old notices some swelling in the child's ankles. The nurse presses against the ankle bone for five seconds,then releases the pressure and notices a markedly slow disappearance of the indentation
Due to these physical findings,the nurse would be most concerned with assessing
1. skin integrity,especially in the lowerextremities.
2. urine output.
3. level of consciousness.
4. range of motion and ankle mobility.
Answer:2
Rationale:Dependent,pitting edema,especially in the lower extremities,can be a symptom of both kidney and cardiac disorders.Decreases in urine output can also indicate compromise in both the renal and cardiac systems.Changes in level of consciousness,if present,would more than likely be a later effect in this situation. 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.
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