The nurse is reviewing the function and repair of the skin with a patient recovering from burns. Which proteins should the nurse explain as being found in the dermis? (Select all that apply.)
a. Sebum
b. Elastin
c. Keratin
d. Collagen
e. Cerumen
f. Adipose tissue
ANS: C, D
Keratinocytes produce the protein keratin. Collagen is the most abundant protein in the body. A. Sebum is a lipid substance. B. Elastin makes the dermis elastic. E. Cerumen is wax. F. Adipose tissue is subcutaneous tissue, not associated with protein.
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After spinal shock has been resolved, an indwelling catheter is removed. What way should the nurse expect this patient to empty the bladder?
a. Manual expression (Credé method) b. Spontaneous reflexive action c. Normal voluntary control d. Self-catheterization
The client is scheduled for a functional assessment using the Functional Independence Measure (FIM). He asks the nurse, "What is the purpose of the FIM?" What is the nurse's best response?
A. "It is a tool that is used to determine your level of independence." B. "It measures how you should be able to perform various tasks." C. "It is a tool to measure the severity of your disability." D. "It is a test the nurse manager uses to determine staffing patterns."
When the nurse assesses the client's abdominal superficial reflexes, the umbilicus moves in the direction of the skin stimulated. The nurse documents this observation as:
1. A positive (+) response. 2. A negative (-) response. 3. An absence of response. 4. A questionable response.
When caring for the client receiving epoetin alfa recombinant, the nurse should:
a. shake the product thoroughly prior to administration. b. monitor the client for hypotension. c. notify the health care provider if the hematocrit reaches 36%. d. monitor the client's white blood cell (leukocyte) count.