What is the most important element in the management of pressure injuries?
A. All members of the health care team should take steps to prevent pressure injuries.
B. Standard precautions are used for all patient skin care.
C. Prevention devices are only used when a stage 3 or 4 injury is present.
D. Only patients with risk factors can develop pressure injuries.
Answer: A
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The charge nurse is reviewing the care plans written by the unit's staff nurses. The charge nurse recognizes that the NANDA nursing diagnosis most likely to be construed as culturally biased and possibly offensive is:
1. Interrupted family processes related to shift in family roles secondary to demands of illness. 2. Fear related to separation from support system during hospitalization. 3. Noncompliance related to impaired verbal communication secondary to recent immigration from a non-English-speaking area. 4. Spiritual distress related to discrepancy between beliefs and prescribed treatment.
The nurse interviewed a client who participated reluctantly, answering questions with minimal
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The nurse learns that a client of the Jewish faith does not eat certain types of foods and fasts on religious holidays. Which intervention would help support the client's cultural practice?
1. Research the client's practices. 2. Obtain a consult with the dietician. 3. Document the client's preferences on the assessment form. 4. Communicate the client's practices to the healthcare team.