A client's spouse reports the presence of a reddened area on her husband's coccyx. She feels a massage would be helpful in promoting circulation to the area. The nurse responds to this suggestion by saying:
1. "Massaging the area twice daily will help restore circulation and should be incorporated into the plan of care.".
2. "I will record these findings in the medical record.".
3. "Massaging the area may actually cause more harm to a potentially compromised area of skin.".
4. "I will need to obtain an order from the physician to perform a massage.".
3. "Massaging the area may actually cause more harm to a potentially compromised area of skin.".
Rationale:
The presence of redness may indicate the presence of a stage I pressure ulcer. Massage can cause a friction-like response to compromised skin and should be restricted when problems are noted. Massages, when therapeutic, do not require a physician's order.
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Unit practice requires inspection of all items being brought onto the unit by visitors. This can be most effectively done by
A. having a staff member sit at the door and check packages as visitors enter. B. having a staff member make frequent rounds during visiting hours to inspect gifts. C. asking all visitors to report to the nurse's station before visiting a client. D. asking clients to give staff any unsafe item that might have been left by a visitor.
Which of the following is necessary to administer proper HRT combinations to postmenopausal women?
A. Testing fasting blood glucose B. Monitoring symptoms experienced C. Testing bone mineral density D. Monitoring hormone blood levels
Which discharge instruction is appropriate for an adolescent client who is a paraplegic due to a motor vehicle accident, in order to prevent decubitus ulcer formation on the buttock?
1. Contract the muscles 5 times every 2 hours. 2. Increase fat in the diet to provide a protective coating over the bony prominences. 3. Do wheelchair push-ups every 15 to 30 minutes. 4. Avoid use of sheepskin, as it prevents air from reaching the area.
List the functions of vitamin A.
What will be an ideal response?