The nurse is caring for a patient who has right-sided paralysis after a cerebrovascular accident (stroke). Which of the following factors would be most likely to result in pressure ulcer formation for this patient?
a. Poor nutrition
b. Immobility
c. Reduced hydration
d. Skin secretions
B
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A Poor nutrition is a risk factor for developing a pressure ulcer but is not the primary risk factor for this patient.
B The patient who has right-sided paralysis is at increased risk for a pressure ulcer developing because of immobility. When restricted from moving freely, dependent body parts are exposed to pressure, reducing circulation to affected body parts. The inability to turn or change position increases the risk for pressure ulcers.
C The patient is not identified as having reduced hydration.
D Skin secretions increase the risk for developing a pressure ulcer; however, this patient's greatest risk factor is having impaired mobility.
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The nurse executive of a hospital is surveying hospitals in a four-state area in regard to their disaster preparedness. The nurse would expect to hear which response to the question "What have you done to prepare for a disaster?"
1. "We have conducted a drive to get area health care professionals registered so they can be contacted in case of a disaster." 2. "We have a designated place with beds and equipment so that staff can be directed to an alternate care area." 3. "We have not prepared for a disaster." 4. "We conduct practice disaster drills."
A geriatric patient has to administer frequent eye drops in both eyes prior to cataract surgery. Which action is most important for the client to consider when administering eye drops?
A) The patient gently draws the lower eyelid down to create a sac to instill the medication. B) The medication is inserted into the outer canthus of the eye. C) The patient looks down when instilling the eye drops into the eye. D) The medication should touch the eye membrane.
The client is a 35-year-old male who was diagnosed with hypertension one year ago. His current drug regime includes enalapril 40 mg by mouth daily
The client confides to the nurse that he is experiencing sexual dysfunction and plans to stop his medication. The nurse's best response is: a. "Sexual dysfunction can be an adverse effect of this medication, but you shouldn't stop this medication without discussing it with your doctor. Changes can be made that should eliminate this effect." b. "Sexual dysfunction is not a result of this medication. Keep taking it as prescribed and try to determine the real cause of the sexual problem." c. "Sexual dysfunction is a frequent adverse effect of this medication. Stop taking it immediately." d. "Sexual dysfunction can result after taking this medication, but hypertension is a more serious problem, so you should continue taking the medication as prescribed."
All of the following are major concepts in Roy's Adaptation Model EXCEPT
A. Environment. B. Health. C. Unity. D. Goal of nursing.