A patient is admitted with a leg wound with a large amount of pus exudate. The nurse assesses that which part of the immune process is functioning?
1. The complement system causing cellular destruction
2. The natural killer lymphocytes circulating through the lymph
3. The neutrophils arriving at the wound as the first line of defense
4. The macrophages circulating in the blood
Answer: 3
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The nurse is checking peripheral perfusion to a child's extremity following a cardiac catheterization. If there is adequate peripheral circulation, the nurse would find that the extremity:
1. Has a capillary refill of greater than three seconds. 2. Is warm, with a capillary refill of less than three seconds. 3. Has decreased sensation with a weakened dorsalis pedis pulse. 4. Has a palpable dorsalis pedis pulse but a weak posterior tibial pulse.
A patient is having her tonsils removed. The patient asks the nurse what function the tonsils normally serve. Which of the following would be the most accurate response?
A) "The tonsils separate your windpipe from your throat when you swallow." B) "The tonsils help to guard the body from invasion of organisms." C) "The tonsils make enzymes that you swallow and which aid with digestion." D) "The tonsils help with regulating the airflow down into your lungs."
A patient has been diagnosed with erectile dysfunction; the cause has been determined to be psychogenic. The patient's interdisciplinary plan of care should prioritize which of the following interventions?
A) Penile implant B) PDE-5 inhibitors C) Physical therapy D) Psychotherapy
The nurse explains that, in addition to the NANDA stem and etiology, the complete nursing diagnosis should include:
a. a time reference for meeting the need. b. a designation of what the patient should do. c. signs and symptoms of the problem as-sessed. d. a specifically worded medical diagnosis.