The nurse is planning care for an older client who has very thin skin on the backs of the hands and arms. What is the client's priority problem?
a. Risk for injury
b. Infection
c. Poor self-image
d. Discomfort
A
Thinning skin, with decreased attachment between the dermis and the epidermis, is at increased risk for injury in response to even minimal trauma or shearing events. If injury occurred, infection would be a possible problem. Thin skin should not cause discomfort. Poor self-image does not take priority over the risk for injury.
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a. Serum electrolyte levels b. Kidney function tests c. Complete blood cell count d. Antinuclear antibodies
After the second week of orientation the new nurse witnesses the death of a child in the ED. Which role should this nurse's preceptor focus on at this time?
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A client has a red spot over the sacrum that does not blanch when the nurse applies pressure. The nurse would document this stage of pressure ulcer formation as being:
a. Stage II. c. Stage IV. b. Stage I. d. Stage III.
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a. Intuition. b. A set of rules. c. Articles in journals. d. Advice from supervisors.