The nurse is assessing an elderly patient and notices a ...

[asmith134]

The nurse is assessing an elderly patient and notices a significant drooping of the eyelid. The nurse recognizes this as which of the following?
 
  a. Ectropion of the eyelid
  b. Entropion of the eyelid
  c. Impairment of the fourth cranial nerve
  d. Ptosis of the eyelid

Question 2

A patient with cancer is undergoing outpatient chemotherapy. The clinic nurse notes that the patient's white blood cell count is very low and has little energy. The plan of care is based upon the nursing diagnosis Risk for Infection.
 
  The nurse provides patient teaching in order to reduce the risk for infection. The nurse is using which skill in this situation? a. Medical diagnosis
  b. Scientific method
  c. Diagnostic reasoning
  d. Data collection

[whitcassie]

Answer to Question 1

D
An abnormal drooping of the lid over the pupil is called ptosis, caused by edema or impairment of the third cranial nerve. In the older adult, ptosis results from a loss of elasticity that accompanies aging. An older adult frequently has lid margins that turn out (ectropion) or in (entropion).

Answer to Question 2

C
The nurse used diagnostic reasoning by using data (low white blood cells and little energy) to arrive at a patient's health problem/nursing diagnosis (Risk for Infection). Diagnostic reasoning is the analytical process for determining a patient's health problems. It requires you to assign meaning to the behaviors and physical signs and symptoms presented by a patient. Nurses do not make medical diagnoses; they make nursing diagnoses. The scientific method is one formal way (in this scenario the nurse did not use the formal approach) to approach a problem, plan a solution, test the solution, and come to a conclusion; it is usually used in research. Data collection is a component of assessment in the nursing process. In diagnostic reasoning you use patient data that you gather or collect to logically identify a problem. The nurse in this scenario is past data collection and has made a nursing diagnosis: Risk for Infection.

[asmith134]

YES! Correct, THANKS for helping me on my review

[elyse44]

Gracias!