A client who has sustained multiple fractures of the left leg is in skeletal traction. The nurse has obtained an overhead trapeze to improve the client's bed mobility. To which high-risk area must the nurse pay particular attention during assessment for indications of pressure and skin breakdown?
A. Left heel
B. Scapulae
C. Right heel
D. Back of the head
Answer: C. Right heel
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An infant who was stable for a day after birth now demonstrates pallor, tachycardia, tachypnea, and circumoral cyanosis. The parent asks how the child might have a heart problem when he was stable yesterday
What information by the nurse is most accurate? A. "Blood incompatibilities can cause this problem, so we will test the mother's blood." B. "Symptoms may not appear until fetal circulation routes begin to close after birth." C. "The extra blood from the umbilical cord may have kept the baby stable for a while." D. "Your baby may have gotten an infection during birth that now is causing problems."
A child is born with pseudohermaphroditism. After determining that the baby is a girl through genetic testing, the parents ask about her potential fertility. Which response by the nurse is the most appropriate?
A. "It is impossible to determine that until she reaches puberty." B. "She is fertile but her uterus is abnormal so she can't carry a baby." C. "Because her internal female organs are normal, she probably is fertile." D. "Unfortunately, all babies born with this condition are infertile."
A woman currently uses a diaphragm and spermicide for contraception. She asks the nurse what the major differences are between the cervical cap and diaphragm. The nurse's most appropriate response is:
a. "No spermicide is used with the cervical cap, so it's less messy." b. "The diaphragm can be left in place longer after intercourse." c. "Repeated intercourse with the diaphragm is more convenient." d. "The cervical cap can safely be used for repeated acts of intercourse without adding more spermicide later."
When assessing a patient's skin, the nurse needs to keep in mind that:
A) light-skinned people do not have melanocytes. B) light-skinned and dark-skinned people have the same number of melanocytes. C) melanocytes in light-skinned people do not produce melanin. D) dark-skinned people have more melanocytes than light-skinned people.