The nurse observes that a client has a deep, irregularly shaped area of skin loss extending into the dermis on the lower extremity. How should the nurse document this finding?
1. Fissure.
2. Ulcer.
3. Wheal.
4. Macule.
Answer: 2
1. Fissures are linear cracks with sharp edges.
2. The description defines the characteristics of an ulcer.
3. A wheal is elevated and fluid-filled, with an irregular border.
4. A macule is a flat, non-palpable change in skin color.
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A male client with type 1 diabetes mellitus asks the nurse about taking an oral antidiabetic agent. Nurse Jack explains that these medications are only effective if the client:
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Because the pt is at risk for spinal shock, what does the nurse monitor for?
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