The nurse assesses the stable client and finds cool pale extremities. Which nursing diagnosis does the nurse add to the client's plan of care?
1. Impaired skin integrity
2. Altered tissue perfusion
3. Altered nutritional state
4. Impaired cardiac output
2
2. The nurse adds altered tissue perfusion to the client's plan of care because skin should be warm and pink, indicating adequate tissue oxygenation.
1. The client does not display clinical indicators for impaired skin integrity, yet; however, the client is at risk for impaired skin integrity with inadequate tissue perfu-sion.
3. An altered nutritional state is unlikely to affect the client with cool extremities. The skin color can be pale, however, from iron deficiency anemia.
4. Impaired cardiac output can result in cool, pale extremities when the cardiac output is low; however, the nurse determines the client is stable and does not observe other clinical indicators of low cardiac output.
You might also like to view...
At the well-child clinic the nurse notices that a 26-month-old boy is displaying negative behavior
His mother relates that he refuses to have anything to do with toilet training and often shouts "no!" when given direction. His mother asks what might be the matter with her son. On the basis of knowledge of growth and development, the nurse should reply a. "He is behaving normally for his age. He is striving for independence.". b. "He needs firmer control. He should be scolded when he tells you ‘no' and is defiant.". c. "I suspect he has a serious developmental problem because most children are toilet trained by the age of 2 years.". d. "He seems to be developing some undesirable attitudes. A child psychologist might be able to help you develop a remedial plan.".
__________ prevents radioactive iodine from reaching the thyroid gland by saturating the gland with nonradioactive iodine
Fill in the blank(s) with correct word
The instructions for Norvasc should be written "hold if BP is _________ ________ 100/50
Fill in the blank(s) with correct word
A student nurse has to open a bed for a client. What is the rationale for turning the top bedding down to the foot of the mattress and folding it back on itself when opening a bed for a client?
A) Protects the blanket B) Keeps the rougher blanket away from the client's skin C) Makes it easier for the client to handle the bedclothes D) Shows the client that the bed is ready