The nurse is caring for a dark-skinned African American patient. Which sites should the nurse use evaluate for the presence or absence of cyanosis? (Select all that apply.)
a. Sclera
b. Nail beds
c. Hard palate
d. Soles of the feet
e. Inner aspect of the arm
ANS: B, D
Cyanosis presents as a gray cast to the skin. The nail beds, palms, and soles may have a bluish cast. A. C. Jaundice can be noted in the oral mucosa (particularly the hard palate) and in the sclera closest to the cornea. E. The inner aspect of the arm is not used to evaluate for cyanosis.
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Number the following nursing interventions as they would proceed through the steps of the nursing process
1. ________ Determine if an antianxiety medication is decreasing a client's stress. 2. ________ Measure a client's vital signs and review past history. 3. ________ Encourage deep breathing and teach relaxation techniques. 4. ________ Aim, with client collaboration, for a seven-hour night's sleep. 5. ________ Recognize and document the client's problem.
When implementing interventions for ensuring that the anxiety of a client will return to a tolerable level, why does the nurse encourage the client to identify what he or she perceives to be a threat to emotional equilibrium?
A) It helps anxious clients, as they have a short attention span and reduced ability to concentrate. B) Processing situations verbally gives the client a more realistic perspective on perceived threats. C) It relieves unnecessary distress and helps in performing tasks in correct sequence. D) It helps divert the client's attention from distressing physiologic symptoms to the task at hand.
The nurse is caring for a 68-year-old male client who is receiving enteral nutrition (EN)
The nurse is aware there is an increased risk for refeeding syndrome in this client due to which of the following conditions noted in his past medical history? A) Chronic alcoholism C) Cholecystectomy B) Morbid obesity D) Bariatric surgery
A patient has come to the ambulatory care clinic with a sprain. The nurse correctly differentiates a grade 2 sprain from a grade 3 sprain with the assessment of which finding?
a. Pain b. Swelling c. Bleeding into the joint d. Minor loss of function