While bathing a patient with cancer, a nurse assessed several large new bruises on the patient's upper arms and thighs. What is the best understanding of the possible causes and the correct nurse's actions for these findings?
a. The patient must have fallen last night walking to the bathroom. Teach the pa-tient to use the call bell when assistance is needed.
b. The patient may have disseminated intra-vascular coagulation. The size, shape, lo-cation, color, and tenderness must be re-ported and recorded fully.
c. An intravascular fluid overload is occur-ring because of the chemotherapy. Place the patient on strict input/output (I/O) sta-tus and limit fluids.
d. The patient must have had a drug-induced seizure, which caused arm and leg thrash-ing and the bruises. Report and record the findings, and pad the side rails.
B
These signs of hemorrhage may indicate the oncologic emergency of disseminated intravascular coagulation. Serious signs need to be reported in a timely manner and fully described.
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As the LPN/LVN discusses the care plan with the other staff, they note the following characteristics of a client's "at risk for" nursing diagnosis: Standard Text: Select all that apply
1. Problem statement 2. Factors contributing to the response 3. The words "related to" 4. Defining characteristics manifested by the client 5. Deviation from health
An osteoporosis-related fall necessitated hip replacement surgery for an older female adult who is entering a rehabilitation facility. Which is the nurse's priority goal during this woman's rehabilitation?
a. Eat whole grains, fruits, and vegetables. b. Recapture preoperative mobility status. c. Keep the surgical wound clean and dry. d. Tell her to take two steps into the walker.
Which indicates why the use of power is important to nursing?
1. The nurse manager can use it to evaluate staff. 2. The nurse can better impact and improve client care. 3. The RN can better supervise unlicensed personnel. 4. Power enables the nurse to ethically treat the agitated patient.
Blood accumulation between the skull and periosteum in the newborn is called _________________________
Fill in the blank(s) with correct word