A client presents with a pressure ulcer on the ankle. Which is the first intervention that the nurse implements?
a. Draw blood for albumin, prealbumin, and total protein.
b. Prepare for and assist with obtaining a wound culture.
c. Place the client in bed and instruct him or her to elevate the foot.
d. Assess the affected leg for pulses, skin color, and temperature.
D
A client with an ulcer on the foot should be assessed for interruption in arterial flow to the area. This begins with assessment of pulses and color and temperature of the skin. The nurse can also assess for pulses noninvasively with a Doppler if unable to palpate with his or her fingers. Eleva-tion of the foot would impair the ability of arterial blood to flow to the area. Wound cultures are done after it has been determined drainage, odor, and other risks for infection are present. Tests to determine nutritional status and risk assessment would be completed after the initial assess-ment is done.
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Family members bring their 75-year-old father into the hospital because of what they perceive as deteriorating mental status
They think he should be placed in a nursing home, even though he has no significant chronic health problems. a. Not knowing anything more about this patient other than the above information, compare the expected or "normal" neurological and cognitive assessment data in this healthy 75-year-old to that of a healthy 35-year-old. b. What techniques or strategies would you engage to differentiate neurological alterations due to a disease or pathological condition from expected age-related changes?
The client's family says, "We don't understand what is happening to Dad. He becomes very agitated in the evenings, cussing like a sailor." When responding to the family, which phenomenon will the nurse include?
A) Delirium B) Sundown syndrome C) Anxiety D) Psychosis
A client with heart failure does not have a scale to weigh on at home. What other methods might the client be instructed to use until a scale can be purchased?
1. Instruct the client to see if his or her same belt or shoes are tighter every day. 2. Have the client observe if he or she feels heavier while wearing the same clothing every day. 3. Suggest the client come to the health department every other week to weigh. 4. Have the client notice if his or her rings are tighter.
The school nurse is doing school screening on children, and checking for head lice is part of the screening process. Before checking the head of an Asian child, the nurse should first:
A) Ask permission. B) Put gloves on. C) Ask the child to wait until last, to avoid embarrassing the child. D) Make sure the child understands the reason for the contact.