The nurse is performing a skin assessment on an older African American patient. Which findings would be considered normal for this patient? Standard Text: Select all that apply
1. Bluish gums
2. Many small, dark papules on the face
3. Purple, hard ,smooth area on the upper arm
4. Multiple skin tears with clear fluid drainage
5. Freckle-like pigmentation of the tongue borders
1,2,5
Rationale: Some dark-skinned people have bluish gums.
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An appropriate goal for a patient with the diagnosis of acute confusion is:
a. the patient will use the call light before getting out of bed within 48 hours. b. the patient will use a calendar to remember the date within 48 hours. c. the patient will respond appropriately to questions about place within 48 hours. d. the patient will remain within the unit while in long-term care.
Identify which of the following disorders would result from a decrease in the number of cells. Select all that apply
1. Thrombocytopenia 2. Leukopenia 3. Polycemia 4. Splenomegaly 5. Myeloma
Which laboratory finding should cause the nurse to suspect that a patient is developing hypovolemic shock?
1. Serum sodium of 130 mEq/L (130 mmol/L) 2. Metabolic acidosis validated by arterial blood gases 3. Serum lactate of 3 mmol/L 4. SvO2 greater than 80%
Restorative care guidelines include all of the following EXCEPT:
A) start rehabilitation as soon as possible B) promotion of activity C) getting patients out of the hospital quickly. D) encourage patient decision-making