The nurse notices dimpling of the skin surrounding a palpable mass in the right breast of a female patient. What is the most appropriate action for the nurse to take next?
a. Record this as an expected finding.
b. Palpate the area of dimpling for pain.
c. Palpate the borders of the area of dimpling for irregularity.
d. Tell the patient that dimpling indicates the mass is benign.
ANS: C
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You are caring for a patient with late-stage Alzheimer's disease. The patient's wife tells you that the patient has now become completely dependent and that she feels guilty if she takes any time for herself
What outcomes would be appropriate for the nurse to develop to assist the patient's wife? A) The caregiver learns to explain to the patient why she needs time for herself. B) The caregiver distinguishes essential obligations from those that can be controlled or limited. C) The caregiver leaves the patient at home alone for short periods of time to encourage independence. D) The caregiver prioritizes her own health over that of the patient.
When technology such as a bar-code medication administration (BCMA) system is used as part of the process of medication administration, fewer errors are made. The proper procedure when using the BCMA includes:
a. signing into the system using the patient's ID number. b. typing in the patient's name and room number. c. scanning the patient's ID, MAR, and medication. d. discontinuing the medication if the system signals an error.
An infant returns from surgery for correction of bilateral congenital clubfeet. The infant has bilateral long-leg casts. The toes on both feet are edematous, but there is color, sensitivity, and movement to them
Which action by the nurse is the most appropriate? 1. Call the healthcare provider to report the edema. 2. Elevate the legs on pillows. 3. Apply a warm, moist pack to the feet. 4. Encourage movement of toes.
Which of the following terms describes the filling up of a body part with blood or other fluid?
A. hyperplasia B. engorgement C. enlargement D. hypertrophy