The nurse is caring for a client who has right-sided paralysis after a CVA (stroke). Which of the following factors would be most likely to result in pressure ulcer formation for this client?
a. Poor nutrition
b. Immobility
c. Reduced hydration
d. Skin secretions
B
The client who has right-sided paralysis is at increased risk for a pressure ulcer developing be-cause 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 in-creases the risk for pressure ulcers.
Poor nutrition is a risk factor for developing a pressure ulcer, but is not the primary risk factor for this client.
The client is not identified as having reduced hydration.
Skin secretions increase the risk for developing a pressure ulcer; however, this client's greatest risk factor is having impaired mobility.
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The nurse is educating a patient and the family about different types of stabilization devices. Which statement by the patient indicates that the patient understands the benefit of using a halo fixation device instead of Gardner-Wells tongs?
1. "I will have less pain if I use the halo device.". 2. "The halo device will allow me to get out of bed.". 3. "I am less likely to get an infection with the halo device.". 4. "The halo device does not have to stay in place as long.".
The dosage ordered is found on which of the following?
A. Medication Administration Record (MAR) B. eMAR C. drug label D. prescription
The American Holistic Nurses Association promotes self-care for nurses and recommends that it can be achieved with which of the following?
A. Exercise, breathing, and yoga B. Meditation, healing music, and laughter C. Listing positive things in life and random acts of kindness D. All of the above
When caring for a patient with infective endocarditis of the tricuspid valve, the nurse should monitor the patient for the development of
a. flank pain. b. splenomegaly. c. shortness of breath. d. mental status changes.