Assessment of a patient's leg reveals the presence of a 1.5-cm circular region of necrotic tissue that is deeper than the epidermis. The nurse should document the presence of what type of skin lesion?
A) Keloid
B) Ulcer
C) Fissure
D) Erosion
Ans: B
Feedback:
An ulcer is skin loss extending past the epidermis with the involvement of necrotic tissue. Keloids lack necrosis and consist of scar tissue. A fissure is linear and erosions do not extend to the dermis.
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The charge nurse is reviewing the care plans written by the unit's staff nurses. The charge nurse recognizes that the NANDA nursing diagnosis most likely to be construed as culturally biased and possibly offensive is:
1. Fear related to separation from support system during hospitalization. 2. Spiritual Distress related to discrepancy between beliefs and prescribed treatment. 3. Interrupted Family Processes related to a shift in family roles secondary to demands of illness. 4. Noncompliance related to impaired verbal communication secondary to recent immigration from non–English-speaking area.
A client is being treated for bleeding esophageal varices with a Sengstaken-Blakemore tube. Nursing care will include which of these approaches?
a. allowing the client to assume a position of choice b. emptying the drainage bottle and recording output c. periodically deflating the balloon d. providing sips of ice water every 30 to 45 minutes
A nurse manager is a representative to a committee that intends to revise the goals of the institution. Before attending the first meeting, the nurse would be sure to review which of the following pieces of documentation about the institution?
1. policy and procedure book 2. safety regulations 3. mission statement 4. annual report of revenue
The nurse is assessing a 13-year-old girl with a family history of kidney cancer who has come to the clinic complaining of abdominal pain, nausea, and vomiting
Which of the following findings would the nurse identify as least likely indicative of cancer in a child? A) The child reports rectal bleeding and diarrhea. B) Observation reveals an asymmetric abdomen. C) The child experiences a broken bone without trauma. D) Palpation determines an abdominal mass.