Answer to Question 1
A
The paraplegic (paralyzed) is most at risk. The direct effect of pressure on the skin by immobility is compounded by metabolic changes. Older adult patients and patients with paralysis have a greater risk for developing pressure ulcers. A breast cancer patient is mobile as is the teenager on crutches, which decreases their risk. The middle-age adult is turning, decreasing the risk of pressure ulcers.
Answer to Question 2
B
The nurse used clinical inference because of previous experience as a pediatric nurse and pieces of evidence of acute pain and a high fever. Clinical inference is the process of drawing conclusions from related pieces of evidence and previous experience with the evidence. An inference involves forming patterns of information from data before making a nursing diagnosis. The scientific method is one formal way (in this scenario the nurse did not use the formal approach) to approach a problem, plan a solution, test the solution, and come to a conclusion; it is usually used in research. Effective problem solving involves evaluating the solution over time to be sure that it is still effective and if a problem occurs you try different options. Data collection is a component of assessment in the nursing process. In diagnostic reasoning you use patient data that you gather or collect to logically identify a problem. The nurse in this scenario is past data collection and is making a tentative conclusion.
Measuring Patient Height
Adult Skeleton: Anterior View
THE DIMENSIONS OF PATIENT-CENTERED CARE
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Apply direct pressure to the patient’s wound.