A client with paralysis who has been cared for at home for 5 years has just been admitted. A nurse finds a wound over his left trochanter that is about 4 inches in diameter and exposes the bone. How should the nurse document this finding?
A. Stage I pressure ulcer
B. Stage II pressure ulcer
C. Stage III pressure ulcer
D. Stage IV pressure ulcer
D
The U.S. Department of Health and Human Services pressure ulcer criteria categorize a stage IV ulcer as one in which skin loss is full thickness with extensive destruction, tissue necrosis, or damage to muscle, bone, or supporting structures. When the bone of the trochanter area is visible, there has been tissue loss that includes muscle loss.
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A) Record any changes in weight. B) Avoid coffee or tea. C) Record number of periods of sleepiness. D) Take over-the-counter antidepressants for depression.
A grieving patient asks a nurse what he would get from participating in a grief support group. What benefits can the nurse include when responding? Select all that apply
1. Social support 2. Connection to resources 3. Validation of experience 4. Direction on how to grieve 5. The opportunity to share his story
A pediatric nurse is providing a health promotional education program to a group of preschool parents. One parent asks the nurse the following question: "I have started buying bottled water
How will this affect my children?" It is important for the nurse to educate the mothers that: A) there is a need to determine if the bottled water has fluoride. B) the preschool child should not drink bottled water. C) the preschool child should only drink milk. D) the parent should alternate bottle and tap water.
A patient who is very upset asks the nurse, "My doctor says I have endometriosis. What does it mean?" What is the nurses best response?
a. "It is an early warning sign of endometrial cancer, but you still need more testing." b. "A special type of tissue, called endometrial tissue, is outside of your uterus." c. "Its a special tissue which grows rapidly, but it is not dangerous." d. "It is a type of infection and inflammation of the endometrial tissue."