Author Question: A female elder tells the nurse that she has experienced increasing fatigue and shortness of breath ... (Read 153 times)

ghost! · **on:** Jul 11, 2018

A female elder tells the nurse that she has experienced increasing fatigue and shortness of breath over the last 2 days. Which goal is the nurse's priority?

a. Promote safety to prevent injury
b. Complete nutritional assessment
c. Balance exercise and rest periods
d. Explore the woman's complaints

Question 2

The nurse is conducting an admission assessment on an older adult and notes a small lesion with a multicolor appearance. Which assessment approach should the nurse use?

a. Braden Scale
b. Wound staging
c. ABCD (asymmetry, border, color, diame-ter) rule
d. Pressure ulcer scale for healing (PUSH) tool

Ddddd · **Reply #1 on:** Jul 11, 2018

Answer to Question 1

D

Feedback
A Incorrect. Promoting safety and preventing injury are reasonable goals to include for this adult but are not as important as investigating the chief complaint, because breathing and circulation are two of the three most important physical needs.
B Incorrect. Completing the nutritional assessment for this adult is reasonable be-cause the symptoms can be related to nutritional deficiencies; however, this should be a part of the examination of the chief complaint.
C Incorrect. Balancing rest and exercise is a reasonable approach to a complaint of fatigue and shortness of breath if the adult is deconditioned; however, the nurse must investigate the chief complaint to determine if deconditioning is a factor.
D Correct. Investigating the complaint is the nurse's priority because fatigue and shortness of breath can indicate cardiac disease, especially in women. Women with cardiac disease often manifest atypical symptoms, and since it tends to be treated less aggressively in women, the nurse must be careful not to miss indi-cators of potential cardiac disease. In addition, in investigating the elder's chief complaint, the nurse investigates all possible causes.

Answer to Question 2

C
The ABCD rule is used to assess potential cancerous lesions for asymmetry, border irregularity, color, and diameter. The Braden Scale is used for predicting pressure ulcers. Wound staging is used during the assessment of pressure ulcers. The PUSH tool provides a detailed form that cov-ers all aspects of an assessment.