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Sherpath: Diabetes Mellitus Chapter 21 Test Case Study 4 (Short
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Which of the following is most important b. The clients perception of the pain
when assessing a client's pain
a. The physical location of pain
b. The clients perception of the pain
When asked about pain client complains of Chronic pain
having severe discomfort from arthritis. Vital
signs are unchanged, and client is calmly
watching
While waiting to perform x-rays on an c) Applies ice to the right hand
individuals right hand according to
nonpharmacological pain management
practice, pain can be moderated or reduced
if the nurse:
Nurse is evaluating the sites of a client in B) Serous drainage
skeletal traction. The nurse is concerned
with
What is the best method for applying ice? Icing of the strain for 20 minutes at a time every 2 to 3 hours is
What should the nurse monitor? suggested and leaving the ice in place for a longer period of
After applying a compression device, the time may cause additional tissue damage.
nurse should monitor for what Compression wrap must snug yet not so tight to impede
developments? circulation (be alert to fingers and toes becoming cool,
How high is "high enough" when elevating tingling or turning blue in color).
an extremity? Whenever possible, elevation of the injured area above the
level of the heart is useful in helping to minimize swelling
(Giddens, 2013).
, The nurse is completing an admission B. Fibrous tissue replacing damaged tissue when injury is
assessment of a new patient to the unit. The extensive.
nurse notes a long, thin, fading scar on the
patient's abdomen in the right lower
quadrant. The nurse knows that scar tissue
results from
A. Optimal functioning of the inflammatory
process after an injury.
B. Fibrous tissue replacing damaged tissue
when injury is extensive.
C. The development of chronic
inflammation.
D. A surgical incision.
Which of the following patients is at higher D. 79-year-old man with diabetes
risk for inflammatory reactions?
A. 2-year-old girl with a healthy diet.
B. 38-year-old man who is obese.
C. 54-year-old woman in menopause
D. 79-year-old man with diabetes
1st priority in preventing infections is: a. Hand washing
A patient admitted to an acute care floor A. Vasodilation
has rubor of an area of injury on the left
lower extremity. The nurse understands that
this redness is caused by
A. Vasodilation
B. Extravasation
C. Neutrophils
D. Exudate
pH: 7.30 A. Respiratory Acidosis.
pCO2: 58
pO2: 50
O2 Sat: 80%
HCO3: 26normal
A. Respiratory Acidosis.
B. Respiratory Alkalosis
C. Metabolic Acidosis
D. Metabolic alkalosis
A client has an allergic reaction to a newly C. Communicate the allergic response to the physician a
prescribed medication. The nurse places the pharmacist.
highest priority on which action?
A. Instruct the client to remain calm.
B. Document the allergy in the medical
record.
C. Communicate the allergic response to
the physician a pharmacist.
D. Place an agency-approved allergy
bracelet on the client.