The nurse is planning care for her patients and is concerned about skin breakdown and delayed wound healing
Which of the following patients are likely to be at a higher risk for wound heal-ing should they develop a pressure ulcer? (Select all that apply.) a. An elderly female patient with mobility issues
b. A young diabetic patient in traction and on bed rest
c. A teenager receiving chemotherapy
d. An elderly man with stage IV congestive heart failure
e. A middle-aged woman with lupus who is having back surgery but is ambulatory
A, B, C, D
Risk factors that delay wound healing include age (older adults have a diminished inflammatory response), obesity, diabetes, compromised circulation, malnutrition, immunosuppressive therapy, chemotherapy, and high levels of stress. An elderly female is at risk due to her age even though she is mobile; a diabetic is at risk especially if in traction; the teenager on chemotherapy is at risk due to the chemotherapy, which can also affect nutrition status. The elderly man has two risk factors: his age and circulatory status. The woman with lupus may not be on immunosuppressive therapy and has no age-related risk factors.
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The nurse's musculoskeletal assessment of a patient reveals involuntary twitching of muscle groups. How would the nurse document this observation in the patient's chart?
A) Tetany B) Atony C) Clonus D) Fasciculations
The nurse needs to assess the young child's gait and range of motion of the extremities. Which of the following instructions is a commonly used method during this portion of the child's assessment?
1. "I need you to pretend to be a duck. Squat and move forward while flapping your arms.". 2. "Let me see you jump in place on both feet.". 3. "Please hop across the room on one foot and then come back by hopping on the other foot.". 4. "Would you please do some jumping jacks for me?"
In observing the client walk, the nurse notes that the client has a combination of antalgic gait and lurch. What conclusion can the nurse draw from this information?
A. The client has a back injury. B. The client has chronic hip pain. C. The client has an injury to the right leg. D. The client has an injury from vigorous physical exercise.
On assessing a young adult client who is admitted after a suicide attempt and also has a habitual drug-abuse problem, you note that this client is agitated, restless, and sweating, and has obviously begun withdrawal
You note that the client refused medication when the staff tried to administer it in the emergency department. Under the circumstances, what is the next thing you will do? a. Explain to the client that he or she must take the medication because the provider ordered it. b. Make sure the room is quiet with subdued lighting and that there are blankets if needed. c. Talk with the client about the impending discomfort and potential hazards of withdrawal. d. Get an order for restraints so the client will be protected and you can administer the medication.