What would you do next?
You are examining an unconscious patient from another region and notice Beau's lines, a transverse groove across all of her nails, about 1 cm from the proximal nail fold.
A) Conclude this is caused by a cultural practice.
B) Conclude this finding is most likely secondary to trauma.
C) Look for information from family and records regarding any problems which occurred 3 months ago.
D) Ask about dietary intake.
C) Look for information from family and records regarding any problems which occurred 3 months ago.
These lines can provide valuable information about previous significant illnesses, some of which are forgotten or are not able to be reported by the patient. Because the fingernails grow at about 0.1 mm per day, you would ask about an illness 100 days ago. This patient may have been hospitalized for endocarditis or may have had another significant illness which should be sought. Trauma to all 10 nails in the same location is unlikely. Dietary intake at this time would not be related to this finding. Do not assume a finding is necessarily related to a patient's culture unless you have good knowledge of that culture.
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Maria Hernandez, 76 years old, recently sustained a left hip fracture and dislocation while gardening in her yard. She underwent left total hip replacement surgery and is recovering on the orthopedic unit
Maria tells the nurse she is upset and does not feel at peace because she has been unable to attend church as a result of the injury. What is the best response by the nurse? a. Encourage her to read a book, magazine, or newspaper b. Suggest that she watch television to keep her mind distracted c. Offer to call the hospital's chaplain or cler-gyman to come pray with her d. Tell her to sleep so that her body can heal and return to a state of peacefulness
The nurse administers a narcotic for pain to a terminal patient with end-stage pulmonary disease and dementia. After one hour, the patient exhibits facial grimacing and restlessness. How should the nurse interpret these assessment findings?
1. The patient has continuing pain. 2. The patient is experiencing a sleep disorder. 3. The patient requires comfort measures. 4. The patient assessment is is within normal limits.
A nurse assessing older adults in a long-term care facility is aware that which of the following may result in sensory alterations for these clients?
A) Constipation B) Anorexia C) Dry skin D) Presbyopia
A patient is not wearing his eyeglasses. Where should you store them?
a. At the nurses' station b. In the top drawer of the bedside stand c. In the person's closet d. In the person's trunk