During an integumentary assessment the nurse observes multiple areas of ecchymosis over the patient's arms, legs, and upper back. What problems should the nurse consider as causes of these manifestations?
Select all that apply.
1. Septicemia
2. Hemophilia
3. Liver disease
4. Vitamin C deficiency
5. Vitamin K deficiency
Correct Answer: 2, 3, 4, 5
Ecchymosis can be caused by hemophilia, liver disease, and vitamin C or K deficiency. Petechiae can be caused by septicemia.
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A patient who has a mandibular structural abnormality has just been admitted to the postsurgical unit from the PACU following surgical remodeling. To ensure this patient's safety, what action should the nurse prioritize?
A) Ensuring that suction tubing and a deep suction catheter are available at the bedside B) Maintaining all four of the patient's bed rails in a raised position C) Encouraging the patient to temporarily use a bedpan rather than a commode or toilet D) Ensuring that wire cutters or scissors are available at the patient's bedside
A child is brought into the emergency department with vomiting, drowsiness, and blowing respirations. The father reports that the symptoms have been progressing throughout the day. The nurse suspects diabetic ketoacidosis (DKA)
Which nursing action is most important in the management of DKA? A) Give prescribed antiemetics. B) Begin fluid replacements. C) Administer prescribed dose of insulin. D) Administer bicarbonate to correct acidosis.
Most of the antiretroviral drugs are toxic to the:
1. myocardium. 2. central nervous system. 3. kidney. 4. liver.
You notice a 7-year-old child who has begun thumb sucking during an extended hospitalization. According to the parents, this was not part of the child's usual behavior prior to hospitalization. Your response is:
A) Offer to color with the child as a diversion. B) Report this behavior to the child's doctor. C) Tell the child that "only babies suck their thumbs." D) Allow the thumb sucking and say nothing to the child.