The nurse is assessing a patient with chronic obstructive ...

[tuffie]

The nurse is assessing a patient with chronic obstructive pulmonary disease (COPD). Which assessment finding indicates a potential complication and requires the nurse's immediate atten-tion?
 
  a. Distended neck veins
  b. Left lower quadrant tenderness
  c. Urinary output of 40 mL/hr
  d. Excessive coughing

Question 2

The nurse is caring for a patient with the problem statement/nursing diagnosis of Risk for Impaired Skin Integrity Related to Immobility. Which goal/outcome statement best correlates with this diagnosis?
 
  a. The patient will sit in chair at bedside for 15 minutes after each meal.
  b. The nurse will assist the patient to chair every shift.
  c. The nurse will assess skin and record condition every shift.
  d. The patient will change positions fre-quently.

[jointhecircus]

Answer to Question 1

A
Cor pulmonale is enlargement of the right side of the heart as a result of pulmonary hypertension caused by constriction of the pulmonary vessels in response to hypoxia. Constant hypoxia sti-mulates erythropoiesis, with resulting polycythemia and increased viscosity of blood. Eventually, right-sided heart failure causes systemic venous congestion which manifests with distended neck veins. The patient would experience right upper quadrant tenderness from an engorged liver. Urinary output of 40 mL/hr is normal. Excessive coughing does not indicate an urgent complica-tion.

Answer to Question 2

A
The goal/outcome statement is directed at the etiology and should be patient oriented. The state-ment should be realistic and measurable and reflect what the patient will do.

[tuffie]

Excellent

[kusterl]

TYSM