A nurse inspecting a client's pressure ulcer documents the following: full-thickness tissue loss; visible subcutaneous fat; bone, tendon, and muscle are not exposed. This pressure ulcer is categorized to be at which of the following stages?
A) Stage I
B) Stage II
C) Stage III
D) Stage IV
Ans: C
In stage III there is full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle are not exposed. In stage I there is intact skin with nonblanchable redness of a localized area, usually over a bony prominence. In stage II there is partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough. In stage IV, there is full-thickness tissue loss with exposed bone, tendon, or muscle.
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The nurse is caring for a patient in the initial phase of treatment for a partial-thickness burn. The patient has been stabilized, with blood pressure 140/88 mm Hg, pulse 78 beats/min, respirations 22 breaths/min, and temperature 97.4°F (36.3°C)
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A patient has been taking prednisone for several weeks after experiencing a hypersensitivity reaction. To prevent adrenal insufficiency, the nurse should ensure that the patient knows to do which of the following?
A) Take the drug concurrent with levothyroxine (Synthroid). B) Take each dose of prednisone with a dose of calcium chloride. C) Gradually replace the prednisone with an OTC alternative. D) Slowly taper down the dose of prednisone, as ordered.
A psychiatric–mental health nurse with decades of practice experience has noted that there has been an increased interest in the spiritual aspects of health. To which of the following reasons has this increased interest been attributed?
A) Research findings suggesting that a spiritual life benefits health B) A decrease in the use of complementary and alternative medicine C) Research findings indicating that lack of religion contributes to mental illness D) The belief that health and spirituality are independent
List at least five facts or pieces of information that you should obtain in shift report.
What will be an ideal response?