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Dif applyingapplication ref 441 key vascular

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DIF: Applying/Application REF: 441KEY: Vascular perfusionMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Management of Care7.A nurse cares for an older adult client who has a chronic skin disorder. The client states, I have not been tochurch in several weeks because of the discoloration of my skin. How should the nurse respond?a.I will consult the chaplain to provide you with spiritual support.b.You do not need to go to church; God is everywhere.c.Tell me more about your concerns related to your skin.d.Religious people are nonjudgmental and will accept you.ANS: CClients with chronic skin disorders often become socially isolated related to the fear of rejection by others.Nurses should assess how the clients skin changes are affecting the clients body image and encourage the cliento express his or her feelings about a change in appearance. The other responses are not appropriate.
DIF: Applying/Application REF: 444KEY: Support| copingMSC: Integrated Process: Communication and DocumentationNOT: Client Needs Category: Psychosocial Integrity8.A nurse assesses a client who has open lesions. Which action should the nurse take first?a.Put on gloves.b.Ask the client about his or her occupation.c.Assess the clients pain.d.Obtain vital signs.ANS: ANurses should wear gloves as part of Standard Precautions when examining skin that is not intact. The otheroptions should be completed after gloves are put on.DIF: Remembering/Knowledge REF: 445KEY: Standard Precautions| skin lesions/woundsMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Safe and Effective Care Environment: Safety and Infection Control9.A nurse assesses a client who has a chronic skin disorder. Which finding indicates the client is effectivelycoping with the disorder?a.Clean hair and nailsb.Poor eye contactc.Disheveled appearanced.Drapes a scarf over the faceANS: AThe nurse should complete a psychosocial assessment to determine if the client is coping effectively. Signs ofadequate coping include clean hair, skin, and nails; good eye contact; and being socially active. A disheveledappearance and draping a scarf over the face to hide the clients appearance demonstrate that the client may behaving difficulty coping with his or her condition.DIF: Understanding/Comprehension REF: 444KEY: Skin lesions/wounds| copingMSC: Integrated Process: Nursing Process: AssessmentNOT: Client Needs Category: Psychosocial Integrity10.A nurse assesses a client and identifies that the client has pallor conjunctivae. Which focused assessmentshould the nurse complete next?a.Partial thromboplastin timeb.Hemoglobin and hematocritc.Liver enzymesd.Basic metabolic panelANS: BPallor conjunctivae signifies anemia. The nurse should assess the clients hemoglobin and hematocrit to confirmanemia. The other laboratory results do not relate to this clients potential anemia.

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