A nurse evaluates the following data in a client's chart: ...

[lidoalex]

A nurse evaluates the following data in a client's chart:
 
  Admission Note
  Laboratory Results
  Wound Care Note
  66-year-old male with a health history of a cerebral vascular accident and left-side paralysis
  White blood cell count: 8000/mm3
  Prealbumin: 15.2 mg/dL
  Albumin: 4.2 mg/dL
  Lymphocyte count: 2000/mm3
  Sacral ulcer - 4 cm  2 cm  1.5 cm
  Based on this information, which action should the nurse take?
  a.
  Perform a neuromuscular assessment.
  b.
  Request a dietary consult.
  c.
  Initiate Contact Precautions.
  d.
  Assess the client's vital signs.

Question 2

A nurse assesses a client who has a lesion on the skin that is suspicious for skin cancer, as shown below:
 
  Which diagnostic test should the nurse anticipate being ordered for this client?
  a.
  Punch skin biopsy
  b.
  Viral cultures
  c.
  Wood's lamp examination
  d.
  Diascopy

[brittrenee]

Answer to Question 1

ANS: B
The white blood cell count is not directly related to nutritional status. Albumin, prealbumin, and lymphocyte counts all give information related to nutritional status. The prealbumin count is a more specific indicator of nutritional status than is the albumin count. The albumin and lymphocyte counts given are normal, but the prealbumin count is low. This puts the client at risk for inadequate wound healing, so the nurse should request a dietary consult. The other interventions do not address the information provided.

Answer to Question 2

ANS: A
This lesion is suspicious for skin cancer and a biopsy is needed. A viral culture would not be appropriate. A Wood's lamp examination is used to determine if skin lesions have characteristic color changes. Diascopy eliminates erythema, making skin lesions easier to examine.

[lidoalex]

TYSM

[daiying98]

Gracias!