A nurse is caring for a patient with a nursing diagnosis of ...

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A nurse is caring for a patient with a nursing diagnosis of Hearing deficit related to presbycusis. Which assessment of the patient would indicate an adaptation to the sensory deficit?
 
  a. The patient frequently cleans out his ears with a cotton swab.
  b. The patient turns one ear toward the nurse during conversation.
  c. The patient isolates himself from social situations.
  d. The patient asks the nurse to speak loudly during conversations.

Question 2

A patient who is suspected of having vascular insufficiency to the lower extremities is assessed by the nurse to have which one of the following?
 
  a. Increased hair growth on the legs and feet
  b. Dull appearance of the skin
  c. Erythema on elevation of the feet
  d. Diminished pedal pulses

[cam1229]

Answer to Question 1

B
Adaptation for a sensory deficit indicates that the patient alters his behavior to accommodate for his sensory deficit, such as turning the unaffected ear toward the speaker. Cleaning the ear would not have an effect for a patient with presbycusis. Avoiding others because of a sensory deficit is maladaptive. Asking the nurse to speak loud alters the environment but does not adapt the patient's behavior.

Answer to Question 2

D

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A The patient with vascular insufficiency of the lower extremities would have decreased hair growth on the legs and feet.
B The patient with vascular insufficiency typically has a shiny appearance of the skin of the lower extremities.
C The patient with vascular insufficiency characteristically shows blanching of the skin on elevation.
D The patient with vascular insufficiency of the lower extremities may exhibit diminished pedal pulses and even diminished posterior tibial pulses.

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TYSM

[ttt030911]

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