The nurse would record the assessment of a nonblanching reddened area on an older client's sacrum as
a. atopic dermatitis.
b. intertrigo.
c. stage 1 pressure ulcer.
d. xerotic eczema.
C
A reddened area that cannot be blanched, especially if it is on a bony prominence, is indicative of a stage 1 ulcer. Precautions should be taken at this point so that the ulcer does not progress.
You might also like to view...
A nurse is initiating a peripheral venous access IV infusion ordered for a client presurgically. In what position would the nurse place the client to perform this skill?
A) High-Fowler's B) Low-Fowler's C) Sims' D) Dorsal recumbent
The nurse is talking with a patient who is thinking about obtaining a second opinion regarding the surgeon's recommendation for surgery. Which response by the nurse is considered an advocacy response?
A) "You have one of the best surgeons in the area. I think it would be a waste of time to seek another opinion." B) "Your surgeon has always given you the best care and is genuinely concerned with your health." C) "You can do what you want, but I would get the surgery done as soon as possible." D) "Let us know if we can answer any further questions after you obtain your second opinion."
A patient with acute respiratory distress syndrome (ARDS) is being cared for in a CCU. The nurse implements the ventilator bundle of care. Which of the following statements about this action is true?
A) Bundles of care strategies combine several strategies that have been shown to improve patient outcomes. B) A ventilator bundle is a group of ventilator equipment ordered together from respiratory care. C) Protocols for care are called bundles in critical care to differentiate them from routine care. D) Each bundle is a defined set of ventilator settings to be used for particular disease processes.
A patient at a small hospital tells the diet aide that he dislikes green beans. The aide tells him that he could have carrots instead with dinner. The menu described is:
a. restaurant b. nonselective c. catering d. preselect