While palpating the nail bed of an African American patient, the nurse notes that the nails have linear bands along the nail edge. How would the nurse evaluate this finding?
1. It likely indicates a nutritional deficiency.
2. This is a common finding in dark-skinned individuals.
3. Additional areas should be assessed for cyanosis.
4. The patient has a fungal infection of the nail bed.
2
Rationale 1: A vitamin deficiency may cause nails to have pits, transverse grooves, or lines, but the nurse would consider a different etiology for this finding in this patient.
Rationale 2: Dark-skinned individuals may have brownish pigmented areas or linear bands along the nail edge.
Rationale 3: The nail beds of a patient who is cyanotic have a bluish hue.
Rationale 4: A fungal infection of the nail usually causes deformed, cracked nails that turn yellow or brown.
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A 51-year-old female client who is 2 days postoperative in a surgical unit of a hospital is at risk of developing atelectasis as a result of being largely immobile. Which of the following teaching points by her nurse is most appropriate?
A) "Being in bed increases the risk of fluid accumulating between your lungs and their lining, so it's important for you to change positions often." B) "You should breathe deeply and cough to help your lungs expand as much as possible while you're in bed." C) "Make sure that you stay hydrated and walk as soon as possible to avoid us having to insert a chest tube." D) "I'll proscribe bronchodilator medications that will help open up your airways and allow more oxygen in."
The nurse is caring for a client with Hodgkin's disease. On a particular day, the client develops respiratory distress. Which of the following measures should be taken by the nurse to help the client get relief?
A) Change the position of the client. B) Keep the neck in midline and place the client in a high Fowler's position. C) Administer oxygen immediately. D) Administer oral or topical antipruritic medication.
The nurse has identified that a patient has 24 health issues to be included on the problem list. What can the nurse do to help focus on the patient's most acute health care needs first?
A) Place the problems in alphabetical order. B) Separate the list into active and inactive problems. C) List the problems according to body system. D) Ask the patient which problem is the highest priority.