A patient has discoloration of an area of their mucous membrane caused by extravasation of blood into the subcutaneous tissue. The nurse should document that the patient has:
a. dyspnea.
b. cyanosis.
c. diaphoresis.
d. ecchymosis.
D
Ecchymosis is discoloration of an area of the skin or mucous membrane caused by the extravasation of blood into subcutaneous tissues as a result of trauma to the underlying blood vessels or by fragility of the vessel walls (also called a bruise).
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A nurse manager approves two staff nurses to attend a national conference. When reviewing the budget, the nurse manager looks at which line item?
a. Cash budget b. Capital budget c. Operating budget d. Supply and expense budget
The physician has ordered amiodarone (Cordarone). Prior to starting this medication, the nurse would alert the physician to which laboratory result?
1. Sodium 140 mEq/L 2. Potassium 3.1 mEq/L 3. Potassium 5.1 mEq/L 4. International normalized ratio (INR) of 12 seconds
The nurse recognizes which of the following as the largest contributing factor for the rise in the need and use of home care?
1. Government funding of the home care setting has increased greatly. 2. Clients are more acutely ill when discharged from the acute care facility. 3. There are 7 days/week services for the elderly in home care agencies. 4. The existence of more single-income families has increased the need for their el-derly relatives to receive care in the home.
A client with moderate to severe dementia does not remember her son's name. The son repeated-ly questions the mother when he visits the dementia facility, asking, "Do you know my name?"
The mother invariably becomes agitated. The nurse can most effectively intervene by explaining to the son: 1. "Your mother is angry with you and is punishing you by ‘forgetting' who you are. Be patient and she'll get over it." 2. "I know it is difficult for you, but your mother's dementia is severe and she can-not retain information even for short periods of time. She senses your distress and becomes agitated." 3. "Although it's a strain for you, you will need to reorient your mother as often as you can, during the time you are with her. With repetition, she may be able to understand and recall what you are saying." 4. "Because you become so distressed, it might be better if you come to see your mother only once a week and stay for only a short time."