The client is at risk for impaired skin integrity related to the need for several
weeks of bedrest. The nurse evaluates the client after 1 week and finds skin integrity is not impaired. In evaluating the plan of care, what is the nurse's best
action?
- A. Remove the nursing diagnosis in the plan of care since it has not occurred
- B. Change the nursing diagnosis in plan of care to impaired mobility
- C. Modify the nursing diagnosis in plan of care to impaired skin integrity
- D. Keep the nursing diagnosis in the plan of care the same since the risk factors are
still present
Correct Answer: D
Rationale:
You may also like to solve these questions
A client with acquired immunodeficiency syndrome (AIDS) has pneumocystis
carinii (PCP). What is the nurse's priority assessment for this client?
- A. Skin turgor
- B. Lung sounds
- C. Radial pulses
- D. Capillary refill
Correct Answer: B
Rationale:
The nurse assesses a deep wound. The area is covered by black and necrotic
tissue. What term would the nurse use when documenting this wound?
- A. Tunnelling
- B. Eschar
- C. Blanching
- D. Cellulitis
Correct Answer: B
Rationale:
A nurse is teaching a client who has fibromyalgia about strategies that might
help reduce her symptoms. What should the nurse include in the client
education?
- A. Avoid exercise during flare-ups
- B. Do high impact exercises like running
- C. Establish a regular sleep pattern
- D. Increase calcium and caffeine intake
Correct Answer: C
Rationale:
What is a classic symptom assessed in clients with lupus?
- A. Butterfly rash
- B. Chvostek's sign
- C. Ovid's sign
- D. Heberden's nodes
Correct Answer: A
Rationale:
What are some of the expected outcomes when medications are given for
rheumatoid arthritis?
- A. Increased quality of life
- B. Increased range of motion
- C. Decreased pain
- D. Cure the disease
Correct Answer: C
Rationale:
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