A patient has a pressure ulcer on the ear where an oxygen cannula has been in place. The ulcer is shallow and long and has a black wound bed. How would the nurse stage this ulcer?
1. Stage II
2. Stage III
3. Stage IV
4. Unstageable
4
Rationale 1: Stage II is partial-thickness loss of dermis with a pink or red wound bed.
Rationale 2: Stage III is full-thickness tissue loss. Slough may be present, but the wound bed is visible.
Rationale 3: Stage IV is full-thickness loss with exposed bone, tendon, or muscle. The wound bed is visible.
Rationale 4: This wound in unstageable because the wound bed is covered in eschar. When eschar is removed, the wound will be stageable.
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A client states to the nurse, "I read that my antidysrhythmic drug can actually cause me to have irregular heartbeats. How can this be?" Which response should the nurse provide the client?
A. "Your medication blocks the flow of the electrolytes in your heart, and this can cause irregular beats." B. "The literature is not always accurate, but if you have concerns I recommend discussing them with your healthcare provider." C. "The aspirin that you take every day will help you avoid experiencing the irregular heartbeats." D. "Your prescription is not the problem; it is when you mix it with over-the-counter (OTC) drugs that you develop irregular beats."
An 8-year-old boy with a fractured forearm is to have a fiberglass cast applied. What information would the nurse include when teaching the child about the cast?
A) The cast will take a day or two to dry completely. B) The edges will be covered with a soft material to prevent irritation. C) The child initially may experience a very warm feeling inside the cast. D) The child will need to keep his arm down at his side for 48 hours.
Which disease form is associated with identified empirical risks?
a. Polygenic b. Multifactorial c. Monozygotic d. Genetic