The nurse collects the following assessment data: right heel with reddened area that does not blanch. Which nursing diagnosis will the nurse assign to this patient?
a. Imbalanced nutrition: less than body requirements
b. Ineffective peripheral tissue perfusion
c. Risk for infection
d. Acute pain
ANS: B
The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ineffective peripheral tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition do not support the data in the question.
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The nurse teaching a patient recently diagnosed with myasthenia gravis should tell him that it is caused by:
A) Genetic dysfunction B) Upper and lower motor neuron lesions C) Decreased conduction of impulses in an upper motor neuron lesion D) A lower motor neuron lesion
Which patient behavior would require the most immediate limit-setting?
a. The patient makes self-deprecating remarks. b. At a goal-setting meeting, the patient interrupts others to express delusions. c. A patient shouts at a roommate, "You are perverted! You watched me undress." d. During dinner, a patient manipulates an older adult patient to obtain a second dessert.
The most abstract level of knowledge is the
A. Paradigm. B. Metaparadigm. C. Theory. D. Concept.
A client's labor has progressed so rapidly that a precipitous birth is occurring. What should the nurse do?
1. Go to the nurse's station and immediately call the physician. 2. Run to the delivery room for an emergency birth pack. 3. Stay with the client and ask auxiliary personnel for assistance. 4. Hold back the infant's head forcibly until the physician arrives for the delivery.