Mrs. Bryant is a 78-year-old patient with diabetes who recently moved into an assisted living apartment because she needs assistance with bathing and housework
When the assistive nursing personnel bathed her for the first time, she noticed that there was a large blister on her right heel. She asked Mrs. Bryant about it, and she denied knowledge of having injured herself. It was re-ported to the nurse who correctly documented it as what stage of a pressure ulcer? A. Stage I
B. Stage II
C. Stage III
D. Stage IV
B
Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister
Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle
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The nurse teaching clients about the effects of herbal remedies explains that wording on the label of supplements may state which of the following?
1. "Helps relieve muscle aches or pain." 2. "For use to relieve symptoms of the cold virus." 3. "Reduces a rapid heart rate." 4. "Promotes vascular health."
The young man who had a bronchoscopy 1 hour ago asks when he can eat. Which response would be most helpful?
a. In 24 hours, but must take cold liquids for the rest of the day b. If there is no blood in his sputum c. In 8 hours after a period of nothing by mouth d. When the gag reflex returns
A client who asked for and was refused a pass to leave the unit left the nurse's station and went to
his room, where he slammed his closet door several times while looking for a sweater. This behavior exemplifies a. displacement. b. sublimation. c. conversion. d. reaction formation.
Many nursing diagnoses in the human response patterns:
a. evaluate the quality of care b. determine whether the client is in danger c. rely on the client's subjective evidence d. evaluate the nurse-client communication process