100%(10)10 out of 10 people found this document helpful
This preview shows page 17 - 20 out of 28 pages.
Global Rationale: Cognitive Level: AnalyzingClient Need: Health Promotion and MaintenanceClient Need Sub: Nursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 50-1Question 22Type: MCSAA patient is diagnosed with a compound fracture and is scheduled for immediate surgery. Which nursing diagnosis would have the highest priority in the immediate postoperative period?1. Impaired Transfer Ability2. Risk for Post-Trauma Syndrome3. Risk for Infection4. Risk for FallsCorrect Answer: Rationale 1: The patient may have difficulty with transfers, but this is not the greatest priority.Rationale 2: Depending on the reason for the injury and the patient’s response, post-trauma syndrome may be applicable. This is not the greatest priority.Rationale 3: The patient with an open, compound fracture has multiple bone breaks penetrating through the skin and must be assessed and cared for vigilantly for signs of infection.Rationale 4: The patient is at risk for a fall due to fracture, but this is not the highest priority.3Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: DiagnosisLearning Outcome: 50-4Question 23Type: MCMA
The nurse should assess a patient with a long leg cast for which signs that would indicate compromised circulation?Note: Credit will be given only if all correct choices and no incorrect choices are selected.Standard Text: Select all that apply.Global Rationale: Cognitive Level: AnalyzingClient Need: Physiological IntegrityClient Need Sub: Physiological AdaptationNursing/Integrated Concepts: Nursing Process: AssessmentLearning Outcome: 50-4Question 24Type: MCSAA patient is diagnosed with a sprained right ankle. The nurse instructs the patient on which common treatment of sprains?