Proper documentation regarding the assessment of a pressure ulcer must include which of the following information concerning the wound? (Select all the apply.)
1. Presence of pain
2. Depth of damage
3. Length and width
4. Presence of drainage
5. Description of drainage
6. Condition of surrounding tissue
ANS: 2, 3, 4, 5, 6
Assessment includes depth of tissue involvement (staging), type and approximate percentage of tissue in wound bed, wound dimensions, exudate description, and condition of surrounding skin. Presence of pain is not a component of this charting.
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The nurse is performing an eye-screening clinic at a daycare center. When examining a 2-year-old child, the nurse suspects that the child has a "lazy eye" and should:
a. Examine the external structures of the eye. b. Assess visual acuity with the Snellen eye chart. c. Assess the child's visual fields with the confrontation test. d. Test for strabismus by performing the corneal light reflex test.
A male patient has a waist of 42 inches and hips that are 35 inches. What would be your conclusion about his waist to hip ratio?
a. He has a "pear" distribution of body fat. b. It is associated with the adverse morbidity and mortality of obesity, cardiovascular disease, and diabetes. c. It is normal. d. It is associated with bulimia nervosa.
A client expresses concern that her 2-hour-old newborn is sleepy and difficult to awaken. The nurse explains that this behavior indicates which of the following?
A) Normal progression of behavior B) Probable hypoglycemia C) Physiological abnormality D) Inadequate oxygenation
A patient with heart failure asks the nurse why two diuretic drugs, furosemide (Lasix) and spironolactone (Aldactone), have been prescribed. What is the nurse's best response?
a. "Your prescriber wants you to lose fluids and that's why you are taking two di-uretics." b. "Each of these diuretics works in a different way to decrease workload on your heart." c. "Using two diuretics will double the amount of fluid you lose to decrease the work your heart must do." d. "Let me contact your prescriber because patients usually do not take two diuretics at the same time."