Which of the following entries is charted correctly? a. wound ...

[vinney12]

Which of the following entries is charted correctly?
 
  a. wound appears the same as yesterday
  b. range of motion improved today
  c. more oriented
  d. 100-ml coffee ground-appearing emesis

Question 2

A client comes into the emergency department complaining of the inability to feel his hands and feet after waiting for 2 hours for transportation in 20F weather. To help this client, the nurse should:
 
  1. Rub and massage the hands and feet.
   2. Warm the hands and feet in tepid water for 2 hours.
   3. Warm the hands and feet in 104F water for 20 to 30 minutes.
   4. Provide an antipyretic.

[Chocorrol77]

Answer to Question 1

D
Avoid using judgmental language such as good, poor, bad, normal, abnormal, decreased, appears to be, and seems.. Avoid evaluative statements such as patient is lazy or patient is uncooperative. Use specific statements or actions that can be observed. Remember to describe what was observed, not what the nurse did.

Answer to Question 2

3. Warm the hands and feet in 104F water for 20 to 30 minutes.

Rationale:
The client's inability to feel his hands and feet after spending 2 hours in 20F weather would indicate the client is experiencing frostbite. Rapid thawing decreases tissue necrosis and should be done by warming the hands and feet in 104F water for 20 to 30 minutes. The hands and feet should not be rubbed. Tepid water will not rapidly warm the hands and feet. Antipyretics would be indicated for a fever.

[vinney12]

TYSM

[matt95]

Excellent