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MDC 1 ATI (QUESTIONS AND ANSWERS) VERIFIED 100% CORRECT!! A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of skin malignancy€15,31
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MDC 1 ATI (QUESTIONS AND ANSWERS) VERIFIED 100% CORRECT!! A nurse is performing a skin assessment for a client who expresses concern about skin cancer. Which of the following findings should the nurse identify as a potential indication of skin malignancy
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MDC 1 ATI
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MDC 1 ATI
Rasmussen University MDC I Final Exam Spring 2023 Latest Update!!
Infection signs and symptoms
fever, BP drops, high respiratory rate, fast heart rate, altered mental status
if wound gets infected it may be red and hot
Hyperthermia temperature
Above 99.5
antipyretics, ice packs under ar...
Rasmussen University MDC I Final Exam Spring 2023
Latest Update!!
Infection signs and symptoms
fever, BP drops, high respiratory rate, fast heart rate, altered mental status
if wound gets infected it may be red and hot
Hyperthermia temperature
Above 99.5
antipyretics, ice packs under armpits, take off layers of clothing
Hypothermia temperature
Below 96.4 F
blankets
Normal body temperature
98.6 F or 37 C
nursing interventions to decrease risk of pressure injury: positioning
pad - pad hard surfaces with pressure redistribution properties
do not elevate - do not elevate head of bed greater than 30 degrees
suspend - suspend heels off the bed surface
nursing interventions to decrease risk of pressure injury: nutrition
encourage protein intake at each meal
serve protein shakes between meals
nursing interventions to decrease risk of pressure injury: skin care
complete a daily skin inspection
moisture dry skin with lotion
do not massage bony prominences
nursing interventions to decrease risk of pressure injury: skin cleaning
clean - clean skin asap after soiling occurs
pat - pat skin dry
use - use tepid rather than hot water
Dosage and Calc Basic Conversions
1 tsp = 5 mL
1 tbsp = 15 mL
1 oz = 30 mL
1 cup = 8 oz
16 oz = 1 lb
1 kg = 2.2 lbs
1 L = 1 kg
1 kg = 1000g
1 g = 1000 mg
1 mg = 1000 mcg
98.6 F = 37 C
,1 cup = 0.5 pint
1 pint = 480 mL
Signs and Symptoms of HIV/AIDS
Wasting Syndrome - skinny and lost a lot of weight in a short period of time
skin lesions
malaise
fever
anorexia
flu like symptoms
night sweats
non-hodgskins lymphoma risk
Kaposi's Sarcoma - skin lesions that occur primarily in individuals with a compromised
immune system
HIV: CD4 and CD8
CD4 is decreased
CD8 is normal
AIDS: CD4 and CD8
CD4 is decreased
CD8 is increased
CD4 count less than 200 equals
AIDS
Antiretroviral drugs - combination drug therapy
HIV patients on it for life
It stops the virus from replicating
already have HIV and exposed again
progression to AIDS is faster
HIV/AIDS Labs
CD4 and CD8 counts
HIV Viral Load testing - highest after infection
Other Assessments
-pulmonary function test
-liver spleen scans
-chest x-ray
Priority of HIV patient is to
prevent infection
Prevent Infection Compromised Immunity
avoid crowds
bathe daily with antimicrobial soap
wash hands thoroughly
avoid raw fruits and vegetables
avoid working in the garden or with houseplants
monitor for signs and symptoms of infection
-increase temperature
-purulent drainage
, -foul smelling drainage
-cloudy urine
Prevent Infection when Hospitalized Compromised Immunity
-private room
-clean patient room and bathroom daily
-vital signs every 4 hours
-change gauze dressings daily
-encourage cough and deep breathing exercises
-strict aseptic technique for invasive procedures
-no fresh flowers or potted plants in room
-avoid undercooked meat
steroids
increase blood sugar
delay bone healing
mask infection
manage pain
pressure relieving mattress pads
warms baths or hydrotherapy
massage
heat or cold packs
lift sheets
drug therapy
enhance nutrition
high calorie and high protein diet
small frequent meals
manage diarrhea
no alcohol or caffein
Restore skin integrity
Lesions from kaposi sarcoma, herpes, and varicella
keep lesions clean to avoid infection
analgesic management
dress to disguise the lesions
Enhance cognition
reorient x3
short simple directions
maintain safe environment, bed alarms, side rails
implement seizure precautions
-padded side rails
-padded tongue blade
-side rails up
-oxygen and suctioning equipment
Glaucoma
increased intraocular pressure in a hollow organ
Glaucoma Primary open angle
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