The nurse assesses clients who have a pressure ulcer. Which does the nurse use to recognize a stage III pressure ulcer?
1. Nonblanching and reddened areas of intact skin
2. Extensive destruction of the skin and the muscle
3. Full-thickness skin loss from surface down to bone
4. Full-thickness skin loss from surface down to fascia
4
4. A stage III ulcer involves damage or necrosis of subcutaneous tissue extending down to, but not through, the fascia.
1. A nonblanching area of reddened skin is a stage I pressure ulcer.
2 and 3. Stage IV pressure ulcers are full-thickness ulcers involving extensive tissue destruction and necrosis of subcutaneous tissue, fascia, muscle, and bone.
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The most important factor in successfully initiating a restraint-free environment is
a. Providing in-service training of nursing staff about restraint policies and procedures b. Educating the residents and families regarding restraint-free principles c. Reviewing the Patient's Bill of Rights with the whole staff so that they understand the right of the resident to choose to be unre-strained d. Discussing safer methods of restraining residents
An older adult client with terminal lung cancer is not breathing well and has cold and mottled skin. The client has a living will and requests comfort measures only. What should the nurse do to help this client?
A) Ask the family what they want to be done for the client. B) Withhold all care until the client dies. C) Contact the physician for orders to control the client's breathing. D) Provide the client with pain medication as ordered.
A patient who is also a nurse is being treated for anxiety with a selective serotonin reuptake inhibitor. She asks about the rationale for use of this agent rather than a benzodiazepine. Which of the following is the nurse's best response?
a. "Selective serotonin reuptake inhibitors are better for the control of bodily symp-toms than benzodiazepines." b. "Selective serotonin reuptake inhibitors provide a more rapid and durable re-sponse to the uncomfortable anxiety symptoms." c. "Benzodiazepines currently have no role in the treatment of anxiety." d. "Selective serotonin reuptake inhibitors are better for reducing the cognitive and psychic symptoms of anxiety than benzodiazepines."
Which assessment does the nurse use to determine the adequacy of circulation in a client whose blood osmolarity is 250 mOsm/L?
a. Measuring urine output b. Measuring abdominal girth c. Monitoring fluid intake d. Comparing radial versus apical pulses