The nurse is caring for a patient with peripheral arterial disease who complains of 3/10 pain in the lower extremities. The nurse observes a 0.5 cm ? 1 cm ulcer on the left lower leg, and the lower legs are shiny and hairless bilaterally
The nurse identifies which priority problem state-ment/nursing diagnosis?
a. Injury related to loss of peripheral circula-tion.
b. Acute pain related to ischemia to lower extremities.
c. Altered skin integrity related to ulcers on lower extremities.
d. Insufficient knowledge related to new di-agnosis of hypertension.
C
Altered skin integrity is the priority problem statement/diagnosis in this situation. Acute pain is a nursing diagnosis, but the pain is 3/10 so it is not the priority since there is an open wound. Injury and insufficient knowledge could be problems, but there is not enough information to support these diagnoses.
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Documentation in a patient's record shows: During 5-minute interaction, patient fidgeted, tapped foot, periodically covered face with hands, looked under chair. Stated, "I enjoy spending time with you." Which assessment is most accurate?
a. The patient gave positive feedback about the nurse's communication techniques. b. The nurse is viewing the patient's behavior through a cultural filter. c. The patient's verbal and nonverbal messages were incongruent. d. Psychotic thought processes are likely.
A woman is having her first child. She has been in labor for 15 hours. Two hours ago, her vaginal examination revealed the cervix to be dilated to 5 cm and 100% effaced, and the presenting part was at station 0
Five minutes ago, her vaginal examination indicated that there had been no change. What abnormal labor pattern is associated with this description? a. Prolonged latent phase b. Protracted active phase c. Secondary arrest d. Protracted descent
A nurse was asked whether the agency should offer additional health promotion programming for young mothers in the Two Oaks neighborhood or the Centerville neighborhood. Two Oaks is a village that has a population of 4000 persons, of whom 50 are single mo
whereas Centerville is an urban area of 15,000 people, of whom 150 are single mothers. On the basis of this information, which of the following would be the best response by the nurse? a. Additional programming will be helpful and appropriate in either neighborhood. b. The nurse needs to know the total number of children in these neighborhoods before making a decision. c. The nurse should choose to focus on single mothers in Centerville. d. The nurse should choose to focus on single mothers in Two Oaks.
________ are liquid suspensions used for external application to the skin to relieve pain and swelling.
Fill in the blank(s) with the appropriate word(s).