When writing a plan of care for a patient with psoriasis the nurse would know that an appropriate nursing diagnosis for this patient would be what?
A) Impaired skin integrity related to scaly lesions
B) Acute pain of skin and oral cavity related to blistering and erosions
C) Impaired tissue integrity related to epidermal shedding
D) Anxiety and depression related to disfigurement
Ans: A
Chapter: 56
Client Needs: A-1
Cognitive Level: Application
Difficulty: Moderate
Integrated Process: Nursing Process
Objective: 3
Page and Header: 1694, Psoriasis
Feedback: The nursing assessment focuses on the appearance of the normal skin, the appearance of the skin lesions, and how the patient is coping with the psoriatic skin condition. An appropriate diagnosis for a patient with psoriasis would include Impaired skin integrity as it relates to scaly lesions. Acute pain of the skin and oral cavity relates to the diagnosis of pemphigus. Impaired tissue integrity related to epidermal shedding would be an important nursing diagnosis for the disorder of toxic epidermal necrolysis (TEN). Anxiety and depression related to disfigurement may be seen in the plan of care for a patient undergoing reconstructive surgery.
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The client tells the nurse, "The world will end tonight at midnight. Armageddon is upon us!" Which type of delusion is this?
1. Religious 2. Grandiose 3. Nihilistic 4. Persecutory
According to the Life Changing Event Questionnaire the nurse can predict that a client will be prone
to negative responses to stress if he or she has experienced a a. number of significant losses. b. move within the same city or town. c. change in religious beliefs. d. promotion at work.
A military veteran is being evaluated for traumatic brain injury (TBI). Which nursing assessment data supports such a diagnosis? (Select all that apply.)
a. Baseline blood pressure is 148/96 b. Has been treated for bronchitis twice in the last 8 months c. Patient reports experiencing an average of 3 headaches per week d. Petit mall seizure activity well controlled with antiseizure medication therapy e. Patient reports a weight gain of 15 pounds since returning from deployment 12 months ago.