The 74-year-old client in the nursing home has developed a pressure ulcer on her sacrum. What could be a cause of the development of this ulcer?
A) Inadequate food and fluid intake C) Overhydration
B) Turning freely in bed D) Lack of vitamins B and C
A
Feedback:
Pressure ulcers may be a symptom of inadequate food and fluid intake. They are also often the result of a client either sitting or lying in the same position for long periods of time, therefore frequent turning and repositioning is recommended every 2 hours.
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Which of the following best describes the new national health goals as seen in Healthy People 2020? (Select all that apply.)
a. Achieve a plan for universal basic health care for citizens b. Create social and physical environments that promote good health c. Eliminate health disparities d. Eliminate preventable disease, disability, injury, and premature death e. Achieve health equity f. Promote healthy behaviors at every stage of life
The nurse is caring for a client being weaned from the ventilator, and wants to improve the client's ability to communicate. Which item will the nurse request an order for from the health care provider?
1. Cuffed tracheostomy tube 2. Uncuffed tracheostomy tube 3. Fenestrated tracheostomy tube 4. Obturator
To establish a relationship with a severely withdrawn schizophrenic client being cared for at home
by a supportive family, the most realistic plan would be for the community mental health nurse to a. visit daily for 4 days, then every other day for 1 week; stay with client for 20 minutes, accept silence; state when the nurse will return. b. arrange to spend 1 hour each day with the client, with the focus on asking questions about what the client is thinking or experiencing; avoid silences. c. visit twice daily; sit beside the client with hand on the client's arm; leave if the client does not respond within 10 minutes. d. visit every other day; remind the client of the nurse's identity; tell the client he may use the time to talk or the nurse will work on reports.
Which assessment findings indicate to the nurse that a child has excess fluid volume? Select all that apply
a. Weight gain b. Decreased blood pressure c. Moist breath sounds d. Poor skin turgor e. Rapid bounding pulse