You have admitted a patient diagnosed with malignant melanoma to your unit. The patient is scheduled for a wide excision of the tumor on her back
In writing the plan of care for this patient what major nursing diagnosis would you include?
A) Deficient knowledge about early signs of melanoma
B) Chronic pain related to surgical excision and grafting
C) Depression related to reconstructive surgery
D) Anxiety related to lack of social support
Ans: A
Feedback: Based on the nursing assessment data, the patient's major nursing diagnoses may include the following: Acute pain related to surgical excision and grafting; Anxiety and depression related to possible life-threatening consequences of melanoma and disfigurement; and Deficient knowledge about early signs of melanoma. Surgical pain is acute, not chronic. The scenario does not indicate reconstructive surgery will be necessary. Lack of social support would not be a major nursing diagnosis for this patient.
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A) The client's wound will be adequately supported at all times. B) The client will not experience skin breakdown in the periwound region. C) The client's wound will remain free of infection at all times. D) The client will remain free of signs and symptoms of inflammation.
An example of a minor modifiable cardiovascular risk factor is
a. hyperlipidemia. c. obesity. b. hypertension. d. smoking.
The nurse should plan to use a wet-to-dry dressing for which patient?
a. A patient who has a pressure ulcer with pink granulation tissue b. A patient who has a surgical incision with pink, approximated edges c. A patient who has a full-thickness burn filled with dry, black material d. A patient who has a wound with purulent drainage and dry brown areas
Which characteristics are risk factors for cerebrovascular accident? Select all that apply
a. Excessive alcohol intake b. Smoking c. Eating large amounts of smoked foods d. Obesity e. Atherosclerosis f. High blood pressure