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A patient who has just undergone a colon resection complains to the nurse that he felt something pop under his dressing while trying to get out of bed. The nurse removes the dressing and finds that dehiscence of the wound has occurred. The nurse's first action should be to:
1. Replace the dressing; dehiscence is normal.
2. Call the physician.
3. Pull the wound edges together, and replace the dressing.
4. Cover the wound with sterile dressings saturated with normal saline.
4. Cover the wound with sterile dressings saturated with normal saline.
The first action of the nurse should be to cover the wound with saline-saturated dressings to prevent damage of the exposed organs from drying and then to call the physician.
A patient who had been complaining of intolerable stress at work has demonstrated the ability to use progressive muscle relaxation and deep breathing techniques. He will return to the clinic for follow-up evaluation in 2 weeks. Which data will best suggest that the patient is successfully using these techniques to cope more effectively with stress?
1. The patient's wife reports that he spends more time sitting quietly at home.
2. He reports that his appetite, mood, and energy levels are all good.
3. His systolic blood pressure has gone from the 140s to the 120s (mm Hg).
4. He reports that he feels better and that things are not bothering him as much.
3. His systolic blood pressure has gone from the 140s to the 120s (mm Hg).
Objective measures tend to be the most reliable means of gauging progress. In this case, the patient's elevated blood pressure, an indication of the body's physiologic response to stress, has diminished. The wife's observations regarding his activity level are subjective, and his sitting quietly could reflect his having given up rather than improved. Appetite, mood, and energy levels are also subjective reports that do not necessarily reflect physiologic changes from stress and may not reflect improved coping with stress. The patient's report that he feels better and is not bothered as much by his circumstances could also reflect resignation rather than improvement.
The sign or symptom that suggests that a patient with impaired skin integrity is developing a systemic infection is a:
1. Lesion on the patient's leg that is swollen and warm to the touch
2. Temperature that has risen to 101° F
3. Blood pressure that has risen from 126/84 to 130/86 mm Hg
4. Request by the patient for medication for severe itching
2. Temperature that has risen to 101° F
A rise in temperature is a systemic response. Normal blood pressure, warmth, swelling, and itching are not evidence of a systemic skin infection.
Small, minute bruises are called:
1. ecchymoses.
2. petechiae
3. spider veins.
4. telangiectasias.
2. petechiae.
Petechiae are smaller than 0.5 cm in diameter. Ecchymoses are larger than 0.5 cm in diameter. Spider veins and telangiectasias are vascular lesions.
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