The nurse is caring for a client with a disabling condition. Which abnormal findings would alert the nurse to an increased risk for skin breakdown? (Select all that apply.)
a. Low serum albumin level
b. High serum transferrin level
c. Low serum carboxyhemoglobin
d. High serum hematocrit
e. Increased weight gain
f. Incontinence
g. Poor fluid intake
A, E, F, G
A low serum albumin level indicates less than adequate nutrition, especially of proteins; this greatly increases the risk for skin breakdown and reduces the rate of wound healing. Protein is a critical nutrient for stimulating DNA synthesis, cell division, and tissue repair. Increased weight gain makes it more difficult to move and puts more pressure on pressure areas. Incontinence of bowel or bladder irritates the skin, making it more prone to breakdown.
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The nurse is preparing to measure the head circumference of a 6-month-old child. How should the nurse make this measurement?
A) From the hairline in front to the hairline in back B) From the center of the forehead to the base of the occiput C) Above the eyebrows through the prominent part of the occiput D) From the middle of the forehead through the parietal prominences
If a client admitted to the hospital for treatment of atrial fibrillation complains of dyspnea and chest pain, the nurse would suspect
a. heart block. b. myocardial infarction. c. pulmonary edema. d. pulmonary emboli.
A parent of a hospitalized child on chemotherapy asks the nurse if a sibling of the hospitalized child should receive the varicella vaccination. The nurse should give which response?
a. The sibling can get a varicella vaccination. b. The sibling should not get a varicella vaccination. c. The sibling should wait until the child is finished with chemotherapy. d. The sibling should get varicella-zoster immune globulin if exposed to chickenpox.
Which nursing diagnosis is likely to apply to an individual with severe and persistent mental illness who is homeless?
a. Insomnia b. Substance abuse c. Chronic low self-esteem d. Impaired environmental interpretation syndrome