During an assessment of the circulation to the extremities, a nurse suspects arterial insufficiency on the basis of which finding?
A. Edema
B. Warm skin
C. Palpable pulses
D. Burning pain that increases with exercise
D
D. Arterial insufficiency results in burning, throbbing, cramping; pain increases with exercise.
A. Edema results from fluid in tissues. Inadequate venous return causes edema in the sacrum if client is confined to bed or in the feet and ankles if sitting.
B. With venous insufficiency skin has normal temperature to touch and a normal, flushed, or cyanotic appearance. With arterial insufficiency skin is cool to touch, pale when elevated, and dusky red when extremity is lowered.
C. Arterial insufficiency results in diminished or absent pulse but is palpable in venous insufficiency.
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According to the theory of thermogenesis, weight control is the result of:
a. a balance between caloric intake and energy expenditure. b. decrease in caloric intake and energy expenditure. c. increase in caloric intake and energy expenditure. d. storage of fat for energy.
The nurse assumes care of a patient who just returned from surgery for a total laryngectomy and radical neck dissection and notes the following problems. In which order should the nurse address the problems?
(Put a comma and a space between each answer choice [A, B, C, D].) a. The patient is in a side-lying position with the head of the bed flat. b. The patient is coughing blood-tinged secretions from the tracheostomy. c. The nasogastric (NG) tube is disconnected from suction and clamped off. d. The wound drain in the neck incision contains 200 mL of bloody drainage.
A nurse has developed a plan of care with nursing interventions designed to meet specific client outcomes. The outcomes are not met by the time specified in the plan. What should the nurse do now in terms of evaluation?
A) Continue to follow the written plan of care. B) Make recommendations for revising the plan of care. C) Ask another health care professional to design a plan of care. D) State "goal will be met at a later date."
Devastated by a divorce from an abusive husband, a wife completes grief counseling. Which statement by the wife should indicate to a nurse that the client is in the acceptance stage of grief?
A. "If only we could have tried again, things might have worked out." B. "I am so mad that the children and I had to put up with him as long as we did." C. "Yes, it was a difficult relationship, but I think I have learned from the experience." D. "I still don't have any appetite and continue to lose weight."