The nurse is assessing the pressure ulcer of a 68-year-old female client. Which of the following would indicate to the nurse that healing is taking place?
1. Eschar
2. Slough
3. Granulation tissue
4. Exudate
ANS: 3
Granulation tissue is red moist tissue composed of new blood vessels, the presence of which in-dicates progression toward healing. Black or brown necrotic tissue is eschar which you will need to remove before healing can proceed. Soft, yellow or white tissue is characteristic of slough (stringy substance attached to wound bed), and you will need to remove this before the wound is able to heal. Wound exudate describes the amount, color, consistency, and odor of wound drainage and is part of the wound assessment. Excessive exudate indicates the presence of infec-tion. The presence of exudate on the skin surrounding the wound is indicative of wound deterio-ration.
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When discussing the use of the term subculture, the nurse recognizes that it is best described as:
a. Fitting as many people into the majority culture as possible. b. Defining small groups of people who do not want to be identified with the larger culture. c. Singling out groups of people who suffer differential and unequal treatment as a result of cultural variations. d. Identifying fairly large groups of people with shared characteristics that are not common to all members of a culture.
The nurse is providing instructions to newly hired graduates for the mini-mental state examination (MMSE). Which statement best describes this examination?
a. Scores below 30 indicate cognitive impairment. b. The MMSE is a good tool to evaluate mood and thought processes. c. This examination is a good tool to detect delirium and dementia and to differentiate these from psychiatric mental illness. d. The MMSE is useful tool for an initial evaluation of mental status. Additional tools are needed to evaluate cognition changes over time.
Which of the following best summarizes the symptoms of a person with bipolar disorder?
a. Chronic, unrealistic, and exaggerated worry about life b. Ongoing hallucinations and delusions c. Changes in mood from depression to mania d. A persistent abnormally elevated or irritable mood
The physician orders continuous intravenous nitroglycerin infusion for the client with MI. Essential nursing actions include which of the following?
A) Obtaining an infusion pump for the medication B) Monitoring BP q4h C) Monitoring urine output hourly D) Obtaining serum potassium levels daily