The nurse is preparing to assess a client with a stage pressure III ulcer. Which findings should the nurse anticipate?
A. Involvement of the epidermal skin layer that may extend into the dermis.
B. A reddened area with skin intact and no involvement of the tissues
C. Ulcer involving muscle and bone.
D. Ulcer that extends into the subcutaneous tissue.
Answer: D
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A client has been taking an opioid for pain relief following abdominal surgery. The client complains of constipation. Which statements indicate understanding by the client? (Select all that apply.)
Note: Credit will be given only if all correct choices and no incorrect choices are selected. 1. "I should only take a laxative when necessary." 2. "I should increase fluid intake." 3. "I should strain when I try to have a bowel movement." 4. "I should increase fiber intake." 5. "I should decrease my physical activity."
The nurse explains Dr. T. Berry Brazelton's Neonatal Behavioral Scale, which identifies six states of reactivity in newborns
The newborn's body is relatively still and his eyes are open. The parents ask which state the baby is in right now, and how should they react to this state? What is the best answer the nurse could give? A) Active alert; rock the baby to sleep B) Active alert; play with the baby C) Quiet alert; rock the baby to sleep D) Quiet alert; play with the baby
A patient who is receiving intravenous (IV) chemotherapy asks why the nurse is wearing a mask, gloves, and gown when giving the drugs. What is the nurse's best response?
a. "These drugs will reduce your immune response, and with these coverings I am protecting you from getting an infection from me." b. "Because your immunity is reduced by this therapy, I am preventing the spread of infection from you to me or any other patient here." c. "The drugs are powerful and I handle them every day. The clothing protects me from accidentally absorbing these strong drugs." d. "The hospital policy is for any nurse giving these drugs to wear gowns, gloves, and masks to prevent other people from getting cancer."
A psychiatric nurse best applies the ethical principle of autonomy by:
a. exploring alternative solutions with a patient, who then makes a choice. b. suggesting that two patients who were fighting be restricted to the unit. c. intervening when a self-mutilating patient attempts to harm self. d. staying with a patient demonstrating a high level of anxiety.