In addition to changing dressings, nursing interventions in wound management include all of the following except
1. Cleaning and debridement.
2. Ensuring that the living environment is clean and supportive of the client's caregivers.
3. Evaluation of efficacy of treatment.
4. Obtaining cultures when indicated.
5. Teaching the client and/or caregiver how to change the dressing using sterile technique.
ANS: 2
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The nurse instructs a client on the steps needed to obtain a peak expiratory flow rate. In which order should these steps occur?
1. "Take as deep a breath as possible." 2. "Stand up (unless you have a physical disability)." 3. "Place the meter in your mouth, and close your lips around the mouthpiece." 4. "Make sure the device reads zero or is at base level." 5. "Blow out as hard and as fast as possible for 1 to 2 seconds." 6. "Write down the value obtained." 7. "Repeat the process two additional times, and record the highest number in your chart." a. 4, 2, 1, 3, 5, 6, 7 b. 3, 4, 1, 2, 5, 7, 6 c. 2, 1, 3, 4, 5, 6, 7 d. 1, 3, 2, 5, 6, 7, 4
The nurse's evaluation of the outcomes of care for an older adult mentally ill client should be guided by the knowledge that:
1. Cultural preferences that conflict with treatment goals take precedence. 2. Complete absence of psychiatric symptoms is the gold standard. 3. Client's values and preferences should be honored whenever possible. 4. Families and significant others are not routinely involved in this process.
An agitated 73-year-old man is brought to the Emergency Department by his daughter after he physically abused his wife
When asked about the incident by the nurse, he said, "My wife is having an affair with my neighbor's 25-year-old son!" What is the best response by the nurse? A) "Did you confront your neighbor about this?" B) "What you are saying makes no sense!" C) "A 25-year old is way too young for your wife." D) "You seem quite upset. Let's talk about this."
The nurse counseling clients with chemical abuse discusses the warning signs with their families. Which of the following is a sign of chemical abuse?
A) Recurrent use-related legal problems B) Need for more of the drug to cause intoxication C) Withdrawal symptoms occur when the client stops using the drug D) Client cannot stop using the drug