A patient from Southeast Asia who has been ill with influenza is admitted with self-inflicted open sores and bruising on both forearms. When questioned about the wounds, the patient states that they were inflicted to aid the healing process
What should the nurse consider when assessing these wounds? 1. The cause of the wounds is unimportant.
2. This may be a cultural practice.
3. The patient belongs to a cult.
4. The patient is delusional.
2
Rationale 1: It is important to determine the cause of the wounds. This is an opportunity for the nurse to educate the patient regarding safe health practices while remaining nonjudgmental.
Rationale 2: The patient's actions may reflect a cultural practice. It is important for the nurse to inquire about any cultural habits or practices that may affect the patient's skin.
Rationale 3: Another explanation is more likely.
Rationale 4: The patient is not necessarily delusional; another explanation is more likely.
You might also like to view...
The nurse is assessing a 9-year-old girl who had tuberculosis when she was 6 years old, has been losing weight, and has no appetite. Which of the following assessment findings would be most indicative of Addison's disease?
A) Arrested height and increased weight B) Thin, fragile skin and multiple bruises C) Hyperpigmentation and low blood pressure D) Blurred vision, headaches, and enuresis
Which of the following statements made by a terminally ill client reflects the best understanding of the purpose of a living will?
1. "It will make sure my wishes are respected." 2. "My family won't be burdened with making those hard decisions." 3. "I don't want strangers making those kinds of decisions for me." 4. "I can make my wishes known while I still have the ability to express them."
What is the priority nursing diagnosis for a patient with antisocial personality disorder who has made threats against staff, ripped art off the walls, and thrown objects?
a. Disturbed sensory perception–auditory b. Risk for other-directed violence c. Ineffective denial d. Ineffective coping
A child diagnosed with hemophilia presents to the emergency department (ED) with multiple injuries following a motor vehicle crash. Which injury is the priority when conducting the nursing assessment?
1. Occipital hematoma 2. Radial fracture 3. Dislocated shoulder 4. Abdominal abrasions