The nurse is documenting an ulcer on the lateral aspect of the client's right great toe. The nurse notes that the ulcer is pale with well-defined edges and there is no evidence of bleeding
Which other assessment data would be useful to determine the origin of this client's ulcer?
1. Skin turgor.
2. Calf measurements.
3. Homan's sign.
4. Peripheral pulses.
Correct Answer: 4
Peripheral pulses should be assessed to determine if the client has arterial insufficiency. This is the most useful assessment at this time. The nurse can use information about the client's skin turgor to help assess the client's fluid balance. Calf measurements can be compared to determine if the client is developing edema. This information will be more helpful to use with a client who has venous insufficiency. Homan's sign can be used to help determine if the client has developed a deep vein thrombosis.
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The most effective means of resolving a conflict occurs when the problem is brought to the attention of the involved parties and attempts are made to resolve it through effective problem solving. This strategy is known as:
1. Confrontation. 2. Resolution. 3. Negotiation. 4. Forcing.
Which of the following is considered to be an immediate response to stress?
a. Constriction of pupils and peripheral blood vessels b. Excessive sweating and weakness c. Fatigue and carbon dioxide retention d. Increased glucose production by the liver
The nurse is interviewing a patient. Which action by the nurse indicates active listening?
a. Asking interview questions while starting an IV b. Correcting the patient's use of the word "free bleeder" for hemophilia c. Asking the spouse to verify the patient's responses to family history questions d. Restating what the patient said to ensure the nurse understands what the patient meant
A patient with Parkinson's disease is taking levodopa/carbidopa (Sinemet) and reports occasional periods of loss of drug effect lasting from minutes to several hours
The nurse questions the patient further and discovers that these episodes occur at different times related to the medication administration. The nurse will contact the provider to discuss: a. administering a catechol-O-methyltransferase (COMT) inhibitor, such as entacapone. b. adding the DA-releasing agent amantadine to the regimen. c. giving a direct-acting dopamine agonist. d. shortening the dosing interval of levodopa/carbidopa.