During a skin assessment, the nurse notes an extravasation of blood into the skin layers that was caused by an injury. Which is most appropriate when documenting this finding?
1) Ecchymosis
2) Petechiae
3) Purpura
4) Telangiectasia
ANS: 1
You might also like to view...
All nursing interventions that are implemented for patients must be documented or charted. Proper documentation of interventions:
a. facilitates communication with all members of the health care team. b. are only considered "legal" if documented in the paper chart. c. leads to errors of omission and repetition of care. d. does not directly measure goal achievement or outcomes.
The recommended children's dosage of Vibramycin is 2 mg/lb of body weight daily divided in two doses on the first day. The child weighs 40 lb. Vibramycin syrup is available in 50 mg/5 mL. The amount for one dose is _______________
a. 4 mL b. 40 mL c. 80 mL d. 0.8 mL
Necrotizing enterocolitis (NEC) is an inflammatory disease of the gastrointestinal muco-sa. The signs of NEC are nonspecific. Some generalized signs include:
a. Hypertonia, tachycardia, and metabolic alkalosis. b. Abdominal distention, temperature instability, and grossly bloody stools. c. Hypertension, absence of apnea, and ruddy skin color. d. Scaphoid abdomen, no residual with feedings, and increased urinary output.
Which action provides the nurse with evidence that a Hispanic patient diagnosed with schizophrenia 10 years ago is likely to continue to benefit from social support after being discharged for a psychotic break?
a. The patient's brother and sister-in-law offer suggestions concerning the support they can provide after discharge b. The patient's mother expresses an understanding of the need for compliance with the treatment plan c. The family's religious leader visits the patient regularly and suggests part-time employment at the church d. Friends of the patient offer to provide transportation to and from therapy sessions that the patient is scheduled to attend