A patient with a diagnosis of insulin dependent diabetes mellitus is being treated for a stage II foot ulcer. The patient refuses to follow an ADA diet as ordered by a physician and is morbidly obese
The nurse assesses the ulcer to be healing, free from signs and symptoms of infection, with a positive pedal pulse and warm to touch. What nursing diagnosis will be identified as a priority?
a.
Infection
b.
Altered nutrition: more than body requirements
c.
Impaired skin integrity
d.
Altered peripheral tissue perfusion
ANS: B
The nurse's assessment identifies no signs of infection, that the wound is healing with positive pedal pulse and skin warm to touch ruling out infection, impaired skin integrity, and altered peripheral tissue perfusion as priorities at this time. The priority nursing diagnosis for this patient is Altered Nutrition: more than body requirements related to diet noncompliance.
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A nurse is providing care for a number of older clients on a restorative care unit of a hospital. Many of the clients have diagnoses or histories of hypertension,
and the nurse is responsible for administering a number of medications relevant to blood pressure control. Which of the following assessments would the nurse be most justified in eliminating during a busy morning on the unit? A) Checking the recent potassium levels of a client receiving an ACE inhibitor B) Measuring the heart rate of a client who takes a ?-adrenergic blocker C) Measuring the pulse of a client taking an ACE inhibitor D) Noting the sodium and potassium levels of a client who is receiving a diuretic
During the death process, the nurse explains that it is believed that the last sense to remain intact is:
1. touch. 2. sight. 3. smell. 4. hearing.
The clinical instructor interprets the development of mutual goals and guidelines as
a. norming. c. storming. b. performing. d. informing.
A client asks if a benign tumor is cancerous. What is the best response by the nurse?
1. No, these rarely require drug treatment. 2. No, but if surgically removed, it will grow back. 3. Yes, this word is often used interchangeably with tumor. 4. Yes, these grow rapidly and can become resistant to treatment.