A patient with a healing leg wound is experiencing a fever and an elevated white blood cell count. Which of the following do these assessment findings suggest to the nurse?
1. normal healing
2. vitamin deficiency
3. infection
4. insufficient intake of protein
3
Rationale: Elevated white blood cells in later phases of wound healing are indicative of an infectious process. Increased body temperature is triggered by microorganisms, bacterial toxins and antigens, and the inflammatory process. Because fever is a manifestation of the inflammatory process and the infectious process, it is important to assess the patient's overall clinical picture for etiologic factors of the fever. A fever and elevated white blood cell count is not seen in normal wound healing, vitamin deficiency, or insufficient intake of protein.
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Which of the following factors will result in a shift of the oxyhemoglobin dissociation curve to the left?
a. Increased PaCO2 c. Increased temperature b. Increased pH d. Increased 2,3-DPG
A long-term care nurse is organizing a depression screening program for the residents. One of the nurse's peers questions why they need to do this, stating, "We are busy enough all ready.". What is the best response by the nurse?
1. "Studies show that as many as 43% of institutionalized elderly adults show symptoms of clinical depression. Depression symptoms are often associated with chronic illness and pain.". 2. "Studies show that as many at 63% of institutionalized elderly adults show symptoms of clinical depression. Depression symptoms are often associated with chronic illness and pain.". 3. "Depression is uncommon in elderly clients, but we need to screen all of our clients to find the few that have symptoms.". 4. "Screening our clients for various diseases will show their families that we are trying to give them the best care possible.".
The nurse is caring for a patient who is an agnostic. Which information should the nurse consider when planning care for this patient?
a. The patient is devoid of spirituality. b. The patient does not believe in God. c. The patient believes there is no known ultimate reality. d. The patient finds no meaning through relationship with others.
In the implementation step of the nursing process, a nurse is to utilize certain activities to be effective in the care of a client. Which activity is the priority?
A) Reassess client's needs. B) Document nursing care. C) Prioritize evaluation of care. D) Differentiate between subjective and objective data.