While collecting data, the nurse suspects that a patient is demonstrating signs of heart failure. What findings did the nurse use to come to this conclusion? (Select all that apply.)
a. Hunger
b. Fatigue
c. Dry cough
d. Ankle edema
e. Shortness of breath when lying down
ANS: B, C, D, E
Manifestations of heart failure include fatigue, dry cough, ankle edema, and shortness of breath when lying down. A. Anorexia is a manifestation of heart failure and not hunger.
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A) Assessment B) Analysis C) Implementation D) Evaluation
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What will be an ideal response?
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You have gathered all needed supplies, and d.s. is as comfortable as possible. You begin the pouchingchange. Using the adhesive remover, with the push-pull method, you gently remove the wafer
As you lift the wafer, you note that the peristomal skin has severe erythema directly encircling the stoma. There is denudation (partial-thickness breakdown) at the medial stoma-skin edge. How should the skin around the stoma look?