The nurse is admitting a client with a pressure ulcer to the long-term care facility. When assessing the wound, the nurse finds partial-thickness skin loss free of eschar. Which stage will the nurse document this ulcer as based on the assessment data?
1. Stage I
2. Stage II
3. Stage III
4. Stage IV
Correct Answer: 2
A stage I ulcer is characterized by erythema that does not resolve within minutes of pressure relief. A stage II ulcer has partial-thickness skin loss free of eschar. A full-thickness loss that goes through the dermis to the subcutaneous tissue but does not extend through the underlying fascia is a stage III pressure ulcer. Stage IV pressure ulcers have full-thickness skin loss, and can involve muscle, joint, and/or bone. This client has a stage II ulcer.
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Which of the following disorders is associated with unintentional weight loss?
A. Clinical depression B. Hyperthyroidism C. Diabetes D. All of the above
The nurse is developing a teaching plan on coping strategies for an extended family of a severely disabled 11-year-old child. What step should the nurse take first in developing this plan?
a. Assess the current coping patterns. b. Establish each member's role. c. Assign specific tasks and deadlines for each member. d. Assess which family member has the most ineffective coping patterns.
The nurse is preparing to assess a client's mental status within the general survey. Which of the following should the nurse use to assess this status?
1. Note the number of times the client looks to significant other while answering interview questions. 2. Ask the client to describe elements of his health history. 3. Study the client's clothing selections. 4. Notice the client's ability to make eye contact during the examination.