The nurse assesses a circular, flat, reddened lesion about 5 cm in diameter on a middle-aged patient's ankle. How should the nurse determine if the lesion is related to intradermal bleeding?
a. Elevate the patient's leg.
b. Press firmly on the lesion.
c. Check the temperature of the skin around the lesion.
d. Palpate the dorsalis pedis and posterior tibial pulses.
ANS: B
If the lesion is caused by intradermal or subcutaneous bleeding or a nonvascular cause, the discoloration will remain when direct pressure is applied to the lesion. If the lesion is caused by blood vessel dilation, blanching will occur with direct pressure. The other assessments will assess circulation to the leg, but will not be helpful in determining the etiology of the lesion.
You might also like to view...
A nursing unit is extremely short staffed. The manager calls a nurse who is on Family and Medical leave (FMLA) to ask the nurse to return to work 2 days prior to schedule. When the nurse declines, the manager becomes insistent
What should be the nurse's first action? 1. Contact a lawyer. 2. Agree to return 2 days early. 3. Contact the human resources director. 4. Contact nursing administration.
7. The nurse offers a client's family a list of community resources and support groups and encourages them to become involved in the local Lupus chapter. This is an example of which professional nursing role responsibility?
a. Client advocate role b. Teaching role c. Caregiver role d. Consultant role
To decrease the probability of systematic variation in a study to evaluate the effects of a teaching program on disease management, the researcher will use which sampling process?
a. Cluster sampling b. Convenience sampling c. Random sampling d. Systematic sampling
A patient comes to the ambulatory care clinic after getting hay into the eyes while farming. Which action(s) should the nurse implement? (select all that apply.)
a. Flush the eye with warm saline. b. Hold the eyelids open. c. Tilt the head back. d. Use a moistened sterile cotton swab. e. Ask the patient to rub the eyes with the lids closed to produce more tears.