The nurse is assessing the skin of a client being admitted to the long-term care facility from an acute care facility. A small blister is noted on the client's right heel. This is documented as
1. A stage I decubitus ulcer
2. A stage II decubitus ulcer
3. A stage III decubitus ulcer
4. A stage IV decubitus ulcer
2
Rationale: A stage I ulcer is a Nonblanchable redness of intact skin
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You are performing an admission assessment on an older adult patient newly admitted for end-stage liver disease. What principle should guide your assessment of the patient's skin turgor?
A) Overhydration is common among healthy older adults. B) Dehydration causes the skin to appear spongy. C) Inelastic skin turgor is a normal part of aging. D) Skin turgor cannot be assessed in patients over 70.
The nurse observes that the handgrip of the client with hypophosphatemia has diminished in strength since the last assessment 2 hours ago. What is the nurse's best first action?
A. Document the finding as the only action. B. Assess respiratory status immediately. C. Apply elastic wraps to the lower extremities. D. Assess deep tendon reflexes.
During menstruation:
a. The endometrium is discharged from the body b. A sex cell is released c. Erectile tissue become hard d. A male sex cell and a female sex cell unite
The nurse is educating patients about dietary selections that will promote wound healing. Which menu options should the nurse include? (select all that apply.)
a. Tofu b. White bread c. Lean beef d. Citrus fruits e. Leafy green vegetables