Which of the following observations regarding ulcer formation on the patient’s lower extremity indicate to the nurse that the ulcer is a result of venous insufficiency? a) The border of the ulcer is irregular. The border of an ulcer caused by arterial insufficiency is circular. b) The ulcer is very painful to the patient, even though superficial. Superficial venous insufficiency ulcers cause minimal pain. c) The ulcer base is pale to black. The base of a venous insufficiency ulcer shows beefy red to yellow fibrinous color. d) The ulcer is deep, involving the joint space. Venous insufficiency ulcers are usually superficial.

Which of the following observations regarding ulcer formation
on the patient’s lower extremity indicate to the nurse that the ulcer
is a result of venous insufficiency?
a) The border of the ulcer is irregular.
The border of an ulcer caused by arterial insufficiency is circular.
b) The ulcer is very painful to the patient, even though superficial.
Superficial venous insufficiency ulcers cause minimal pain.
c) The ulcer base is pale to black.
The base of a venous insufficiency ulcer shows beefy red to yellow
fibrinous color.
d) The ulcer is deep, involving the joint space.
Venous insufficiency ulcers are usually superficial.
by

1 Answer

Answer :

a) The border of the ulcer is irregular.
The border of an ulcer caused by arterial insufficiency is circular.
by

Related questions

Which of the following terms refers to leg pain that is brought on walking and caused by arterial insufficiency? a) Intermittent claudication Intermittent claudication is leg pain that is brought on by exercise and relieved by rest. b) Dyspnea Dyspnea is the patient’s subjective statement of difficulty breathing. c) Orthopnea Orthopnea is the inability of the patient to breathe except in the upright (sitting) position. d) Thromboangitis obliterans Thomroangitis obliterans is a peripheral vascular disease also known as Burger’s disease.

Description : Which of the following terms refers to leg pain that is brought on walking and caused by arterial insufficiency? a) Intermittent claudication Intermittent claudication is leg pain that is ... obliterans Thomroangitis obliterans is a peripheral vascular disease also known as Burger's disease.

Last Answer : a) Intermittent claudication Intermittent claudication is leg pain that is brought on by exercise and relieved by rest.

Which of the following terms refers to a muscular, cramp-like pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest? a) Intermittent claudication Intermittent claudication is a sign of peripheral arterial insufficiency. b) Aneurysm An aneurysm is a localized sac of an artery wall formed at a weak point in the vessel. c) Bruit A bruit is the sound produced by turbulent blood flow through an irregular, tortuous, stenotic, or dilated vessel. d) Ischemia Ischemia is a term used to denote deficient blood supply.

Description : Which of the following terms refers to a muscular, cramp-like pain in the extremities consistently reproduced with the same degree of exercise and relieved by rest? a) Intermittent claudication Intermittent ... or dilated vessel. d) Ischemia Ischemia is a term used to denote deficient blood supply.

Last Answer : a) Intermittent claudication Intermittent claudication is a sign of peripheral arterial insufficiency.

Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b) tolerance to opioids is uncommon. Tolerance to opioids is common. c) addiction to opioids commonly develops. Addiction to opioids is rare. d) the nurse must be primarily concerned about development of addiction by the patient in pain. Addiction is rare and should never be the primary concern for a patient in pain.

Description : Regarding tolerance and addiction, the nurse understands that a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction. b ... pain. Addiction is rare and should never be the primary concern for a patient in pain.

Last Answer : a) although patients may need increasing levels of opioids, they are not addicted. Physical tolerance usually occurs in the absence of addiction.

When gastric analysis testing reveals excess secretion of gastric acid, which of the following diagnoses is supported? a) Duodenal ulcer Patients with duodenal ulcers usually secrete an excess amount of hydrochloric acid.

Description : When gastric analysis testing reveals excess secretion of gastric acid, which of the following diagnoses is supported? a) Duodenal ulcer Patients with duodenal ulcers usually secrete an excess ... anemia Patients with pernicious anemia secrete no acid under basal conditions or after stimulation.

Last Answer : a) Duodenal ulcer Patients with duodenal ulcers usually secrete an excess amount of hydrochloric acid.

Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient’s level of anxiety has decreased? a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

Description : Which of the following patient behaviors, if observed by the nurse, would indicate that the cardiac patient's level of anxiety has decreased? a) Answers questions regarding status with ... in support groups. Participation in support groups indicates some degree of comfort with prognosis.

Last Answer : a) Answers questions regarding status with no problem. Generally, when anxiety begins to increase, the patient will be less likely to want to discuss prognosis.

When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse recognizes that the patient is likely demonstrating signs of a) reflex sympathetic dystrophy syndrome. RSD is frequently chronic and occurs most often in women.

Description : When the patient who has experienced trauma to an extremity complains of severe burning pain, vasomotor changes, and muscles spasms in the injured extremity, the nurse ... heterotrophic ossification. Heterotrophic ossification causes muscular pain and limited muscular contraction and movement.

Last Answer : a) reflex sympathetic dystrophy syndrome. RSD is frequently chronic and occurs most often in women.

Which of the following statements reflect current research regarding the utilization of non-pharmacological measures in the management of burn pain? a) Music therapy may provide reality orientation, distraction, and sensory stimulation. Researchers have found that music affects both the physiologic and psychological aspects of the pain experience. Music diverts the patient’s attention away from the painful stimulus. Music may also provide reality orientation, distraction, and sensory stimulation. It also allows for patient self-expression.

Description : Which of the following statements reflect current research regarding the utilization of non-pharmacological measures in the management of burn pain? a) Music therapy may provide reality orientation, distraction, ... of burn pain. Pet therapy has not proven effective in the management of burn pain.

Last Answer : a) Music therapy may provide reality orientation, distraction, and sensory stimulation. Researchers have found that music affects both the physiologic and psychological aspects of the pain experience ... orientation, distraction, and sensory stimulation. It also allows for patient self-expression.

When the nurse observes the patient’s urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Description : When the nurse observes the patient's urine to be orange, she further assesses the patient for a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake ... white urine may indicate infection, pyruria, or in the female patient, the use of vaginal creams.

Last Answer : a) intake of medication such as phenytoin (Dilantin). Urine that is orange may be caused by intake of Dilantin or other medications. Orange to amber colored urine may also indicate concentrated urine due to dehydration or fever.

Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient’s fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed. b) Minimal urine output of 50 milliliters per hour Minimal urine output may be less than 50 mL/hr. c) Minimal urine output of 10 milliliters per hour Minimal urine output must exceed 10 mL/hr. d) Minimal intake of 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Description : Which of the following statements accurately reflects a rule of thumb upon which the nurse may rely in assessing the patient's fluid balance? a) Minimal intake of 1.5 liters per day If food and fluids are ... 2 liters per day Minimal intake, as a rule of thumb, is less than 2 liters per day.

Last Answer : a) Minimal intake of 1.5 liters per day If food and fluids are withheld, IV fluids (3L/day) are usually prescribed.

In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient’s residual urine must be less than which of the following amounts on two separate occasions (morning and evening)? a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

Description : In assessing the appropriateness of removing a suprapubic catheter, the nurse recognizes that the patient's residual urine must be less than which of the following amounts on two separate occasions ... urine that is greater than 100 cc indicates that the suprapubic catheter cannot be discontinued.

Last Answer : a) 100 cc If the patient complains of discomfort or pain, however, the suprapubic catheter is usually left in place until the patient can void successfully.

The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief. b) vomiting. Vomiting is uncommon in the patient with duodenal ulcer. c) hemorrhage. Hemorrhage is less likely in the patient with duodenal ulcer than the patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Description : The nurse recognizes that the patient with a duodenal ulcer will likely experience a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain ... patient with gastric ulcer. d) weight loss. The patient with a duodenal ulcer may experience weight gain.

Last Answer : a) pain 2-3 hours after a meal. The patient with a gastric ulcer often awakens between 1-2 A.M. with pain and ingestion of food brings relief.

When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for redness and palpated for hardening. b) drainage. Drainage at the site does not indicate a reaction to the tubercle bacillus. c) tissue sloughing. Sloughing of tissue at the site of injection does not indicate a reaction to the tubercle bacillus. d) bruising. Bruising of tissue at the site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Description : When interpreting the results of a Mantoux test, the nurse explains to the patient that a reaction occurs when the intradermal injection site shows a) redness and induration. The site is inspected for ... site may occur from the injection, but does not indicate a reaction to the tubercle bacillus.

Last Answer : a) redness and induration. The site is inspected for redness and palpated for hardening.

When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

Description : When the nurse administers intravenous gamma-globulin infusion, she recognizes that which of the following complaints, if reported by the patient, may indicate an adverse effect of the infusion? a) ... urination is a sign of urinary tract infection, not an adverse effect of gamma-globulin infusion.

Last Answer : a) Tightness in the chest Flank pain, tightness in the chest, or hypotension indicates adverse effects of gamma-globulin infusion.

When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient’s serum electrolytes anticipating which abnormality? a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves). b) Hypercalcemia Hypercalcemia would likely be demonstrated by asystole. c) Hypomagnesemia Hypomagenesemia would likely be demonstrated by hypotension, lethargy, and vasodilation. d) Hyponatremia Hyponatremia would likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Description : When the post-cardiac surgery patient demonstrates restlessness, nausea, weakness, and peaked T waves, the nurse reviews the patient's serum electrolytes anticipating which abnormality? a) Hyperkalemia ... likely be indicated by weakness, fatigue, and confusion without change in T wave formation

Last Answer : a) Hyperkalemia Hyperkalemia is indicated by mental confusion, restlessness, nausea, weakness, and dysrhythmias (tall, peaked T waves).

When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient’s posturing as a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

Description : When the nurse observes that the patient has extension and external rotation of the arms and wrists and extension, plantar flexion, and internal rotation of the feet, she records the patient's ... rotation of the arms and wrists and extension, internal rotation, and plantar flexion of the feet.

Last Answer : a) decerebrate. Decerebrate posturing is the result of lesions at the midbrain and is more ominous than decorticate posturing.

When the patient’s eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

Description : When the patient's eosinophil count is 50-90% of blood leukocytes, the nurse interprets the result as a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell ... d) normal. Eosinophils normally make up 1-3% of the total number of white blood cells.

Last Answer : a) indicative of idiopathic hypereosinophilic syndrome. When eosinophils make up 50-90% of white cell count, the patient is demonstrating severe eosinophilia.

When the nurse notes that the patient’s left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) hammertoe. Hammertoes are usually pulled upward. c) pes cavus. Pes cavus refers to a foot with an abnormally high arch and a fixed equinus deformity of the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Description : When the nurse notes that the patient's left great toe deviates laterally, she recognizes that the patient has a a) hallux valgus. Hallux valgus is commonly referred to as a bunion. b) ... the forefoot. d) flatfoot. In flatfoot, the patient demonstrates a diminished longitudinal arch of the foot.

Last Answer : a) hallux valgus. Hallux valgus is commonly referred to as a bunion.

In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

Description : In order to avoid hip dislocation after replacement surgery, the nurse teaches the patient which of the following guidelines? a) Never cross the affected leg when seated. Crossing the affected leg may result ... a chair. The patient should be taught to avoid bending forward when seated in a chair.

Last Answer : a) Never cross the affected leg when seated. Crossing the affected leg may result in dislocation of the hip joint after total hip replacement.

If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding. b) every hour. Checking for placement each hour is unnecessary unless the patient is extremely restless or there is basis for rechecking the tube based on other patient activities. c) every 24 hours. Checking for placement every 24 hours does not meet the standard of care due the patient receiving continuous tube feedings. d) when a tube feeding is continuous, it is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Description : If tube feeding is continuous, the placement of the feeding tube should be checked a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located ... is unnecessary to check placement. Even though the feedings are continuous, the placement must be assessed.

Last Answer : a) every shift. Each nurse caring for the patient is responsible for verifying that the tube is located in the proper area for continuous feeding.

Which of the following venous access devices can be used for no more than 30 days in patients requiring parenteral nutrition? a) Non-tunneled catheter The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, allows the patient freedom of movement, and provides easy access to the dressing site.

Description : Which of the following venous access devices can be used for no more than 30 days in patients requiring parenteral nutrition? a) Non-tunneled catheter The subclavian vein is the most common vessel used because the ... term home IV therapy (eg, Port A Cath, Mediport, Hickman Port, P.A.S. Port).

Last Answer : a) Non-tunneled catheter The subclavian vein is the most common vessel used because the subclavian area provides a stable insertion site to which the catheter can be anchored, allows the patient freedom of movement, and provides easy access to the dressing site.

Which of the following observations in the patient who has undergone allograft for treatment of burn site must be reported to the physician immediately? a) Crackles in the lungs Crackles in the lungs may indicate a fluid buildup indicative of congestive heart failure and pulmonary edema.

Description : Which of the following observations in the patient who has undergone allograft for treatment of burn site must be reported to the physician immediately? a) Crackles in the lungs Crackles in the lungs ... pain at the recipient site is anticipated since the wound has been protected by the graft.

Last Answer : a) Crackles in the lungs Crackles in the lungs may indicate a fluid buildup indicative of congestive heart failure and pulmonary edema.

During which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? a) Stage III Clinically, a deep crater with or without undermining of adjacent tissues is noted. b) Stage IV A stage IV pressure ulcer extends into the underlying structure, including the muscle and possibly the bone. c) Stage II A stage II ulcer exhibits a break in the skin through the epidermis or dermis. d) Stage I A stage I pressure ulcer is an area of nonblanchable erythema, tissue swelling, and congestion, and the patient complains of discomfort.

Description : During which stage of pressure ulcer development does the ulcer extend into the subcutaneous tissue? a) Stage III Clinically, a deep crater with or without undermining of adjacent tissues is ... area of nonblanchable erythema, tissue swelling, and congestion, and the patient complains of discomfort.

Last Answer : a) Stage III Clinically, a deep crater with or without undermining of adjacent tissues is noted.

When the nurse observes diffuse swelling involving the deeper skin layers in the patient who has experienced an allergic reaction, the nurse records the finding as a) angioneurotic edema. The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit.

Description : When the nurse observes diffuse swelling involving the deeper skin layers in the patient who has experienced an allergic reaction, the nurse records the finding as a) angioneurotic edema. ... the result of increased interstitial fluid and associated with disorders such as congestive heart failure.

Last Answer : a) angioneurotic edema. The area of skin demonstrating angioneurotic edema may appear normal but often has a reddish hue and does not pit.

When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the pain to occur, the nurse recognizes that the patient is describing a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

Description : When the patient with known angina pectoris complains that he is experiencing chest pain more frequently even at rest, the period of pain is longer, and it takes less stress for the ... or refractory angina produces severe, incapacitating chest pain that does not respond to conventional treatment.

Last Answer : a) unstable angina. Unstable angina is also called crescendo or pre-infarction angina and indicates the need for a change in treatment.

When measuring the blood pressure in each of the patient’s arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures. b) must be equal in both arms. The pressures in each arm do not have to be equal in order to be considered normal. c) may vary 10 mm Hg or more between arms. Pressures that vary more than 10 mm Hg between arms indicate an abnormal finding. d) may vary, with the higher pressure found in the left arm. The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Description : When measuring the blood pressure in each of the patient's arms, the nurse recognizes that in the normal adult, the pressures a) differ no more than 5 mm Hg between arm pressures. Normally, in ... . The left arm pressure is not anticipated to be higher than the right as a normal anatomical variant.

Last Answer : a) differ no more than 5 mm Hg between arm pressures. Normally, in the absence of disease of the vasculature, there is a difference of no more than 5 mm Hg between arm pressures.

When the nurse reviews the physician’s progress notes for the patient who has sustained a head injury and sees that the physician observed Battle’s sign when the patient was in the Emergency Department, the nurse knows that the physician observed a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

Description : When the nurse reviews the physician's progress notes for the patient who has sustained a head injury and sees that the physician observed Battle's sign when the patient was in the Emergency Department, the ... CSF) from the patient's nose. Escape of CSF from the patient's nose is termed rhinorrhea.

Last Answer : a) an area of bruising over the mastoid bone. Battle’s sign may indicate skull fracture.

When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

Description : When caring for a patient receiving autolytic debridement therapy, the nurse a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement ... Pancrease. Commercially available enzymatic debriding agents include Accuzyme, Clooagenase, Granulex, and Zymase.

Last Answer : a) advises the patient about the foul odor that will occur during therapy. During autolytic debridement therapy a foul odor will be produced by the breakdown of cellular debris. This odor does not indicate that the wound is infected.

When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume. b) Normal glomerular filtration Indices of normal glomerular filtration are output of 25 ml or greater per hour and specific gravity between 1.010 and 1.025. c) Overhydration Overhydration is manifested by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Description : When the nurse notes that the post cardiac surgery patient demonstrates low urine output (< 25 ml/hr) with high specific gravity (> 1.025), the nurse suspects: a) Inadequate fluid volume Urine ... by high urine output with low specific gravity. d) Anuria The anuric patient does not produce urine.

Last Answer : a) Inadequate fluid volume Urine output of less than 25 ml/hr may indicate a decrease in cardiac output. A high specific gravity indicates increased concentration of solutes in the urine which occurs with inadequate fluid volume.

The nurse reading the physician’s report of an elderly patient’s physical examination knows a notation that the patient demonstrates xanthelasma refers to a) yellowish waxy deposits on upper eyelids. The change is a common, benign manifestation of aging skin or it can sometimes signal hyperlipidemia.

Description : The nurse reading the physician's report of an elderly patient's physical examination knows a notation that the patient demonstrates xanthelasma refers to a) yellowish waxy deposits on upper eyelids. The change is ... red moles. Cherry angioma is the term that is used to describe a bright red mole.

Last Answer : a) yellowish waxy deposits on upper eyelids. The change is a common, benign manifestation of aging skin or it can sometimes signal hyperlipidemia.

For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

Description : For which of the following medications must the nurse contact the pharmacist in consultation when the patient receives all oral medications by feeding tube? a) Enteric-coated tablets Enteric-coated ... make an opening in the capsule and squeeze out contents for administration by feeding tube.

Last Answer : a) Enteric-coated tablets Enteric-coated tablets are meant to be digested in the intestinal tract and may be destroyed by stomach acids. A change of form of medication is required by patients with tube feedings.

When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

Description : When the nurse observes that the patient always has difficulty breathing when lying flat, the nurse records that the patient is demonstrating a) Orthopnea Patients with orthopnea prefer not ... Paroxysmal nocturnal dyspnea. Paroxysmal nocturnal dyspnea refers to orthopnea that occurs only at night.

Last Answer : a) Orthopnea Patients with orthopnea prefer not to lie flat and will need to maintain their beds in a semi- to high Fowler’s position

During which step of the nursing process does the nurse analyze data related to the patient’s health status? a) Assessment Analysis of data is included as part of the assessment. b) Implementation Implementation is the actualization of the plan of care through nursing interventions. c) Diagnosis Diagnosis is the identification of patient problems. d) Evaluation Evaluation is the determination of the patient’s responses to the nursing interventions and the extent to which the outcomes have been achieved.

Description : During which step of the nursing process does the nurse analyze data related to the patient's health status? a) Assessment Analysis of data is included as part of the assessment. b) ... patient's responses to the nursing interventions and the extent to which the outcomes have been achieved.

Last Answer : a) Assessment Analysis of data is included as part of the assessment.

For individuals known to be dying by virtue of age and/or diagnoses, which of the following signs indicate approaching death: a) Increased restlessness As the oxygen supply to the brain decreases, the patient may become restless. b) Increased wakefulness As the body weakens, the patient will sleep more and begin to detach from the environment. c) Increased eating For many patients, refusal of food is an indication that they are ready to die. d) Increased urinary output Based upon decreased intake, urinary output generally decreases in amount and frequency.

Description : For individuals known to be dying by virtue of age and/or diagnoses, which of the following signs indicate approaching death: a) Increased restlessness As the oxygen supply to the ... Increased urinary output Based upon decreased intake, urinary output generally decreases in amount and frequency.

Last Answer : a) Increased restlessness As the oxygen supply to the brain decreases, the patient may become restless.

Surgical fusion of a joint is termed a) arthrodesis. Arthrodesis of a joint is created surgically to treat chronic pain. b) open reduction with internal fixation (ORIF). ORIF refers to surgery to repair and stabilize a fracture. c) heterotrophic ossification. Heterotrophic ossification refers to formation of bone in the periprosthetic space. d) arthroplasty. Arthroplasty refers to surgical repair of a joint or joint replacement.

Description : Surgical fusion of a joint is termed a) arthrodesis. Arthrodesis of a joint is created surgically to treat chronic pain. b) open reduction with internal fixation (ORIF). ORIF refers to ... periprosthetic space. d) arthroplasty. Arthroplasty refers to surgical repair of a joint or joint replacement.

Last Answer : a) arthrodesis. Arthrodesis of a joint is created surgically to treat chronic pain.

The nurse teaches the patient about glargine (Lantus), a “peakless” basal insulin including which of the following statements? a) Do not mix the drug with other insulins Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering glargine (Lantus) insulin it is very important to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.

Description : The nurse teaches the patient about glargine (Lantus), a peakless basal insulin including which of the following statements? a) Do not mix the drug with other insulins Because glargine is in a ... action Glargine is a peakless basal insulin that is absorbed very slowly over a 24-hour period.

Last Answer : a) Do not mix the drug with other insulins Because glargine is in a suspension with a pH of 4, it cannot be mixed with other insulins because this would cause precipitation. When administering ... to read the label carefully and to avoid mistaking Lantus insulin for Lente insulin and vice versa.

Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

Description : Regarding emergency procedures at the burn scene, the nurse teaches which of the following guidelines? a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to ... . Such procedures may worsen the tissue damage and lead to hypothermia in patients with large burns.

Last Answer : a) Never wrap burn victims in ice. Such procedure may worsen the tissue damage and lead to hypothermia in patients with large burns.

When the emergency nurse learns that the patient suffered injury from a flash flame, the nurse anticipates which depth of burn? a) Deep partial thickness A deep partial thickness burn is similar to a second-degree burn and is associated with scalds and flash flames.

Description : When the emergency nurse learns that the patient suffered injury from a flash flame, the nurse anticipates which depth of burn? a) Deep partial thickness A deep partial thickness burn is similar to a ... Injury from a flash flame is not associated with a burn that is limited to the epidermis.

Last Answer : a) Deep partial thickness A deep partial thickness burn is similar to a second-degree burn and is associated with scalds and flash flames.

Which of the following is an indicator of neurovascular compromise? a) Capillary refill more than 3 seconds Capillary refill more than 3 seconds is an indicator of neurovascular compromise. Other indicators include cool skin temperature, pale or cyanotic color, weakness, paralysis, paresthesia, unrelenting pain, pain on passive stretch, and absence of feeling.

Description : Which of the following is an indicator of neurovascular compromise? a) Capillary refill more than 3 seconds Capillary refill more than 3 seconds is an indicator of neurovascular compromise. Other ... d) Pain on active stretch. Pain on passive stretch is an indicator of neurovascular compromise.

Last Answer : a) Capillary refill more than 3 seconds Capillary refill more than 3 seconds is an indicator of neurovascular compromise. Other indicators include cool skin temperature, pale or cyanotic color, weakness, paralysis, paresthesia, unrelenting pain, pain on passive stretch, and absence of feeling.

When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 10-15 seconds In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest. b) 30-35 seconds Applying suction for 30-35 seconds is hazardous and may result in the patient’s developing hypoxia, which can lead to dysrhythmias and, ultimately, cardiac arrest.

Description : When performing endotracheal suctioning, the nurse applies suctioning while withdrawing and gently rotating the catheter 360 degrees for which of the following time periods? a) 10-15 seconds In general ... suction for 0-5 seconds would provide too little time for effective suctioning of secretions.

Last Answer : a) 10-15 seconds In general, the nurse should apply suction no longer than 10-15 seconds because hypoxia and dysrhythmias may develop, leading to cardiac arrest.

Which of the following terms refers to muscular hypertonicity with increased resistance to stretch? a) Spasticity Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes.

Description : Which of the following terms refers to muscular hypertonicity with increased resistance to stretch? a) Spasticity Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished ... d) Myclonus Myoclonus refers to spasm of a single muscle or group of muscles.

Last Answer : a) Spasticity Spasticity is often associated with weakness, increased deep tendon reflexes, and diminished superficial reflexes.

A new biosynthetic dressing used , is used to treat?in the treatment of burns, TransCyte a) burns of indeterminate depth is used to treat burns in which the depth is?TransCyte indeterminate or between superficial and deep partial thickness in depth.

Description : A new biosynthetic dressing used , is used to treat?in the treatment of burns, TransCyte a) burns of indeterminate depth is used to treat burns in which the depth is?TransCyte ... a temporary biosynthetic wound?BCG Matrix covering intended for use with partial-thickness burns and donor sites

Last Answer : a) burns of indeterminate depth is used to treat burns in which the depth is?TransCyte indeterminate or between superficial and deep partial thickness in depth.

The nurse who provides teaching to the female patient regarding prevention of recurrent urinary tract infections includes which of the following statements? a) Void immediately after sexual intercourse. Voiding will serve to flush the urethra, expelling contaminants.

Description : The nurse who provides teaching to the female patient regarding prevention of recurrent urinary tract infections includes which of the following statements? a) Void immediately after sexual intercourse. Voiding ... encouraged to void every 2-3 hours during the day and completely empty the bladder.

Last Answer : a) Void immediately after sexual intercourse. Voiding will serve to flush the urethra, expelling contaminants.

Regarding oral cancer, the nurse provides health teaching to inform the patient that a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of tenderness or difficulty in chewing, swallowing, or speaking.

Description : Regarding oral cancer, the nurse provides health teaching to inform the patient that a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of ... crater-like. A typical lesion in oral cancer is a painless hardened ulcer with raised edges.

Last Answer : a) many oral cancers produce no symptoms in the early stages. As the cancer progresses, the patient may complain of tenderness or difficulty in chewing, swallowing, or speaking.

When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean a) his body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn.

Description : When assisting the patient to interpret a negative HIV test result, the nurse informs the patient that the results mean a) his body has not produced antibodies to the AIDS virus. A negative test ... When antibodies to the AIDS virus are detected in the blood, the test is interpreted as positive.

Last Answer : a) his body has not produced antibodies to the AIDS virus. A negative test result indicates that antibodies to the AIDS virus are not present in the blood at the time the blood sample for the test is drawn.

The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a) solid. With a sigmoid colostomy, the feces are solid. b) semi-mushy. With a descending colostomy, the feces are semi-mushy. c) mushy. With a transverse colostomy, the feces are mushy. d) fluid. With an ascending colostomy, the feces are fluid.

Description : The nurse teaches the patient whose surgery will result in a sigmoid colostomy that the feces expelled through the colostomy will be a) solid. With a sigmoid colostomy, the feces are solid. b) semi- ... colostomy, the feces are mushy. d) fluid. With an ascending colostomy, the feces are fluid.

Last Answer : a) solid. With a sigmoid colostomy, the feces are solid.