A patient is receiving Coumadin for a deep vein thrombosis. The nurse should monitor this patient for which of the following skin lesions?
A) Ulcer
B) Ecchymosis
C) Scar
D) Erosion
Ans: B
Feedback: Ecchymosis refers to a round or irregular macular lesion, which is larger than petechiae and occurs secondary to blood extravasation. It is important to watch for ecchymosis in a patient receiving any type of blood thinner. Refer to Chart 55-3.
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The nurse performs a visual assessment on a patient and is documenting the findings as the acronym PERRLA. What does PERRLA indicate?
a. Palpebral angle rigid, right and left angles b. Patient's eyes round, regular, lively, active c. Pupils equilateral, regular, round, little accommodation d. Pupils equal, round, and reactive to light and accommodation
Which factors could influence pulse measurement? Select all that apply
1. Activity 2. Temperature 3. Stress 4. Antibiotic medications 5. Hydration
The nurse is examining a client experiencing vertigo and wants to perform the Romberg test. The nurse would correctly provide which set of instructions to the client?
1. "Touch your finger to your nose, alternating hands.". 2. "Walk across the room by placing one foot in front of the other, heel to toes.". 3. "Walk on your toes, then on your heels, then on your toes again.". 4. "Stand with your feet together, arms at sides, and eyes open.".
The nurse is reviewing instructions for a
patient with type 2 diabetes who also takes insulin injections as part of the therapy. The nurse asks the patient, "What should you do if your fasting blood glucose is 47 mg/dL?" Which response by the patient reflects a correct understanding of insulin therapy? a. "I will call my doctor right away." b. "I will give myself the regular insulin." c. "I will take an oral form of glucose." d. "I will rest until the symptoms pass."