The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.)
a. Ask whether patient's expectations are being met.
b. Prevent injury to the skin and tissues.
c. Obtain the patient's perception of interventions.
d. Reduce injury to the skin.
e. Reduce injury to the underlying tissues.
f. Restore skin integrity.
B, D, E, F
Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore skin integrity. Asking the patient's perceptions and whether expectations are being met allows one to obtain information regarding the experience, but these are not actual measurable outcomes.
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A new nurse is learning how to prioritize time. One of the best ways that this can be accomplished is for the new nurse to focus on which of the following?
a. Nursing tasks b. Patient priorities c. Medication schedule d. Ancillary procedures
The following are levels of anxiety (select all that apply):
A. Mild. B. Moderate. C. Severe. D. Panic.
A nurse conducted a safety class for a group of older adult clients in the community on fall prevention. Which client action during a follow-up visit in the home indicates understanding of the information presented?
A) All meats have been placed in the freezer. B) The locks on all the doors have been changed. C) Scatter rugs have been placed in the kitchen. D) Non-slip strips have been installed in the shower.
An instructor is explaining the functions, sources, and intake recommendations for vitamins. The instructor realizes additional instruction is required when a student says:
1. "It is vital to consume an adequate amount of most vitamins in our daily diet or through supplements because the body cannot manufacture many of them." 2. "With exposure of the skin to sunlight 15 minutes twice per week, the body can synthesize a significant amount of the needed vitamin D." 3. "Fat-soluble vitamins serve as coenzymes for metabolism throughout the body and help to stimulate appetite, maintain healthy nervous and integumentary systems, and assist with growth." 4. "Because fat-soluble vitamins can be stored, they can become toxic when consumed in excessively large doses over a long period of time."