A child fell off a swing and scraped his right knee. The injured area becomes painful. What else will the nurse observe upon assessment?
a. Vasoconstriction at injured site
b. Decreased RBC concentration at injured site
c. Pale skin at injured site
d. Edema at injured site
ANS: D
Increased vascular permeability and leakage of fluid out of the vessel cause edema at the site of injury. Vasodilation occurs, bringing increased RBCs to the site and causing redness.
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The nurse working the telephone suicide crisis line receives a call from a man who tells her he lives
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A resident in a long-term care facility has difficulty swallowing and frequently chokes on food and liquids. The nurse identifies an increased risk of aspiration. To whom should the nurse in-itiate a referral for a swallowing evaluation?
a. Physician who specializes in throat dis-orders b. Dietitian c. Nutritionist d. Speech therapist
A 20-year-old woman is at 28 weeks' gestation. Her prenatal history reveals previous drug abuse, and urine screening indicates that she has recently used heroin. The nurse should recognize that the woman is at increased risk for:
1. Erythroblastosis fetalis. 2. Diabetes mellitus. 3. Abruptio placentae. 4. Pregnancy-induced hypertension.
A new pediatric hospital will open soon. While planning nursing care,the hospital administration is considering two models of providing health care: family-focused care and family-centered care. The action that best implements family-centered care is
1. telling the family what must be donefor the family's health. 2. assuming the role of an expertprofessional to direct the health care. 3. intervening for the child and familyas a unit. 4. conferring with the family indeciding which health-care option will be chosen.