A preschool paraplegic patient with cerebral palsy is admitted to the hospital with complications from the H1N1 virus. The admitting nurse notes that an area of redness on the right malleolus is nonblanchable
The nurse correctly identifies this pressure ulcer at what stage? a. Stage I
b. Stage II
c. Stage III
d. Stage IV
A
Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister
Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling
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Which nursing instruction related to photosensitivity is highest priority for the client receiving a sulfonamide?
a. "Use a high SPF sunblock when out in the sun." b. "Avoid driving during daylight hours." c. "Take vitamin D to prevent photosensitivity." d. "Apply a moisturizer before going outside."
What will be the nurse's primary goal in the initiation phase during the first visit to homebound clients?
A. Accurately assess the health of all family members and the immediate environment. B. Discuss the time and financial limits to the care the nurse can give. C. Establish rapport with the clients and work with them to define mutually agreeable goals. D. Implement the nursing care plan established before hospital discharge.
What is the final stage of the infectious process?
a. Colonization b. Invasion c. Multiplication d. Spread
The physician orders lorazepam (Ativan) 1 mg po qid for 1 week for a client with generalized anxiety disorder. The nurse should
A. question the physician's order because the dose is excessive. B. explain the long-term nature of benzodiazepine therapy. C. teach the client to limit caffeine intake. D. tell the client to expect mild insomnia.