Which data collection finding should the nurse expect in a patient who has a systemic infection?
a. Warm skin
b. General malaise
c. Skin redness
d. Purulent drainage
ANS: B
Symptoms of systemic infection may include headache, malaise, muscle aches, fever, and anorexia. Manifestations of a local infection also include pain, redness, swelling, and warmth at the site. Purulent drainage occurs from the local inflammatory process.
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A patient's BUN/creatinine ratio is 13:1. How would the nurse interpret this finding?
1. The patient is hypervolemic. 2. Renal tubule dysfunction may be present. 3. The patient is normovolemic. 4. The patient's glomerular filtration rate is decreased.
The nurse is monitoring the laboratory values of a patient with acute pancreatic dysfunction. Which values would indicate further assessment is required?
1. Hemoglobin level 13.5 mg/dL 2. Serum sodium level 143 mEq/L 3. Serum potassium level 4 mEq/L 4. Serum calcium level 8 mg/dL 5. BUN level is 80 mg/dL
Your client is at risk for development of pressure ulcers on the heels. Which of the following nursing interventions would be most appropriate?
1. Watch to see if pressure ulcers develop. 2. Avoid massaging over bony prominences because the pressure may increase the risk of pressure ulcer formation. 3. Suspend the heels off the bed. 4. Wash affected areas with hot water and soap to cleanse the skin.
During a class for teens, a participant admits to frequently "overindulging" in numerous activities, including eating
The teenager questions whether there is an increased likelihood of becoming addicted to alcohol as a result of having an "addictive personality.". What information should be provided to the client? 1. There are no data to support the existence of an addictive personality. 2. Addiction to alcohol is due to heredity and has nothing to do with personality. 3. There is no relationship between addiction and personalities who are prone to "overindulgence.". 4. The client is not at an advanced enough age to make this determination.