The client experienced a sports-related injury to his leg. During the morning assessment, what signs of inflammation will the nurse most likely assess?
1. Swelling
2. Pain
3. Warmth
4. Pallor
5. Pitting edema
1,2,3
Rationale 1: Swelling is a sign of inflammation.
Rationale 2: Pain is a sign of inflammation.
Rationale 3: Warmth is a sign of inflammation.
Rationale 4: Pallor is not a sign of inflammation; redness is.
Rationale 5: Pitting edema is not a sign of inflammation.
Global Rationale: Swelling, pain, and warmth are signs of inflammation. Pallor is not a sign of inflammation; redness is. Pitting edema is not a sign of inflammation.
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Family members bring a patient to the ED with pale cool skin, sudden midsternal chest pain unrelieved with rest, and a history of CAD. How should the nurse best interpret these initial data?
A) The symptoms indicate angina and should be treated as such. B) The symptoms indicate a pulmonary etiology rather than a cardiac etiology. C) The symptoms indicate an acute coronary episode and should be treated as such. D) Treatment should be determined pending the results of an exercise stress test.
During a home visit, the nurse learns that a new mother is experiencing breast engorgement. What should the nurse recommend to help alleviate this problem?
A) Discontinuing breastfeeding for 24 hours B) Having her apply lanolin cream to each breast C) Encouraging her to continue regular breastfeeding D) Decreasing her fluid intake to below 500 ml per 24 hours
A nurse is teaching a patient about self breast examination. What would the nurse emphasize? (Mark all that apply.)
A) Inspection B) Pain C) Timing D) Palpation E) Pallor
What would you include in Mrs Simanski's preoperative teaching plan?
Mrs Deidre Simanski is a 52-year-old woman who has consented for a laparoscopic hysterectomy and bilateral salpingo-oophorectomy for endometrial cancer. She presented at her GP with abnormal uterine bleeding and was subsequently referred to the gynaecological clinic for endometrial biopsy. She lives alone, works part-time in retail and has two grown children, both of whom live interstate with their families—she sees them every 3 months or so. Mrs Simanski smokes 35 cigarettes a day and has a BMI of 39. She also has type 2 diabetes and hypertension. What will be an ideal response?