The nurse is caring for a patient admitted to the hospital from a nursing home. The patient has a stage 3 pressure ulcer. The nurse is asked to document the wound appearance. What is the best way to initially document the appearance of the wound?
a. Use a ruler to accurately measure wound size.
b. Use a clock analogy to describe wound location.
c. Use objective terminology.
d. Take a photograph of the wound.
ANS: D
A photograph is objective and easy to use as a baseline to monitor wound healing progress. Using a ruler, clock analogy, and objective terminology are all important but are not as clear a communication tool as a photograph for documenting appearance.
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A client with systemic lupus erythematosus (SLE) was recently discharged from the hospital after an acute exacerbation. The client is in the clinic for a follow-up visit and is distraught about the possibility of another hospitalization disrupting
the family. What action by the nurse is best? a. Explain to the client that SLE is an unpredictable disease. b. Help the client create backup plans to minimize disruption. c. Offer to talk to the family and educate them about SLE. d. Tell the client to remain compliant with treatment plans.
When working with a perpetrator who has a pattern of violent outbursts followed by remorse, the nurse's plan of care should focus on:
A) Providing punishment for the client's actions. B) Identifying weaknesses. C) Developing effective anger management techniques. D) Notifying the client's employer.
A family member expresses concern to the nurse about behavioral changes in an elderly client. What information would cause the nurse to suspect a dementia disorder?
A) Problems with preparing a meal or balancing a checkbook. B) Increased complaints of physical ailments. C) Sudden disturbed sleep-wake cycle. D) Decreased enjoyment of activities that were once enjoyable.
During a routine check-up a 28-year-old client says that it has been 8 years since the last examination. How often should the nurse instruct the client to have routine check-ups?
1. Every 10 years. 2. When the client experiences health issues. 3. Every year for blood pressure. 4. Every 1-5 years