The nurse is assessing for skin changes in an African-American client admitted with peripheral arterial disease. What does the nurse monitor for?
a. Excess hair growth
b. Pitting edema in the feet
c. Cyanosis of the nail beds
d. Loss of toenails
C
Because only severe cyanosis is evident in the skin of dark-skinned clients, cyanosis can be detected by assessing the skin and nail beds for a dull lifeless color. The soles of the feet and the toenails are less pigmented, which can enable detection of cyanosis or duskiness in the lower extremities. Loss of hair on the lower extremities is noted with peripheral artery disease. Pitting edema is associated with venous disease. Toenail beds are cyanotic, but loss of nails is not associated.
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A male client takes ibuprofen twice a day, every day, for his arthritis. He becomes very anxious when he does not take his normal doses. This client is experiencing:
a. Physical tolerance b. Substance dependency c. Psychological tolerance d. Early-stage addiction
The nurse has identified the goals of maintaining client safety and homeostasis during the intraoperative phase of client care. What nursing activities would support these goals?
1. Maintain the sterile field. 2. Perform instrument counts. 3. Instruct in postoperative exercises. 4. Position the client appropriately for surgery. 5. Perform preoperative skin preparation.
The doctor has prescribed an injection of solu-medrol and occult of all stools for a child with acquired thrombocytopenia. Why should the nurse question the order?
1. Blood in the stools is rare with this illness. 2. Steroids are not an effective treatment. 3. Injections should not be given to a child with this condition. 4. None of the orders are appropriate for a child with this illness.
The nurse who respects the patient's right to refuse treatment is following which bioethical principle?
a. Justice b. Beneficence c. Autonomy d. Fidelity