Author Question: An experienced nurse has just walked into the room of a client to whom the nurse has been assigned ... (Read 132 times)

arivle123 · **on:** Jul 23, 2018

An experienced nurse has just walked into the room of a client to whom the nurse has been assigned for the shift. Which of the following might be a significant observation that could influence the inclusion of a new nursing diagnosis?

1. The client's eyes are closed.
2. The client's skin is pale and mottled.
3. The client's spouse is asleep in the chair next to the bed.
4. The television is on and the volume is turned up.

Question 2

The nurse has formulated a nursing diagnosis of Impaired skin integrity related to poor hygienic practice, secondary to current living conditions. Which of the following data would support this diagnosis? (Select all that apply.)

______ Skin is dry, cracked
______ One large with several smaller open, ulcerated areas on right leg
______ Client does not drive
______ Client states that does not use alcohol or drugs
______ Clothes are soiled
______ Client has obvious body odor

Swizqar · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

Correct Answer: 2
Rationale: Nurses draw on knowledge and experience to compare client data to standards and norms and to identify significant and relevant observations. A sleeping client would not necessarily be recognized as a significant or relevant observation.

Answer to Question 2

Correct Answer: Skin is dry, cracked
One large with several smaller open, ulcerated areas on right leg
Clothes are soiled
Client has obvious body odor
Rationale : Data that support this problem are clustered around the condition of the client's skin, clothes, and general appearance. The facts that the client does not drive and does not use alcohol or drugs do not play a part in this client's skin condition.