The nurse is conducting an admission assessment on an older adult and notes a small lesion with a multicolor appearance. Which assessment approach should the nurse use?
a. Braden Scale
b. Wound staging
c. ABCD (asymmetry, border, color, diame-ter) rule
d. Pressure ulcer scale for healing (PUSH) tool
C
The ABCD rule is used to assess potential cancerous lesions for asymmetry, border irregularity, color, and diameter. The Braden Scale is used for predicting pressure ulcers. Wound staging is used during the assessment of pressure ulcers. The PUSH tool provides a detailed form that cov-ers all aspects of an assessment.
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A postoperative patient is receiving morphine sulfate from a patient-controlled analgesia device. On assessment, the nurse notes that the patient's respirations are depressed
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A client goes to the clinic to report that the medication prescribed to help her get to sleep worked
well when she took it each night for 1 month. However, now that the medication is gone, her insomnia is worse than ever and she has had nightmares the last two nights. The nurse can hypothesize that the physician had prescribed a a. hypnotic. b. neuroleptic. c. central nervous system stimulant. d. tricyclic antidepressant.
A very concerned 14-year-old boy presents to the clinic because of an enlargement of his left breast
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A patient newly diagnosed with diabetes mellitus has nausea, vomiting, and abdominal pain. ABG results include a pH of 7.2 and a bicarbonate level of 20 mEq/L. What other assessment finding should the nurse anticipate in this patient? Select all that apply.
A. Tachycardia B. Dysrhythmias C. Kussmaul respirations D. Weakness E. Cold, clammy skin