The nurse has applied an occlusive dressing to a stage 1 pressure injury and knows that this type of dressing assists in debridement of the wound in which way?
A. It mechanically debrides the wound.
B. Enzymes are applied to the wound to remove necrotic tissue.
C. The dressing maintains a moist environment that uses the body's own enzymes.
D. The dressing dries the injury environment, which encourages sloughing of the injured tissue.
Answer: C
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An adolescent comes to the clinic because of a concern with a skin lesion, and is accompanied by a parent. When the adolescent is called back to the exam room, the parent comes with the adolescent
What approach by the nurse would be most appropriate? 1. Allow the parent to come into the exam room with the adolescent. 2. Tell the parent she cannot come into the exam room with the adolescent. 3. Instruct the parent to stay in the waiting room and the adolescent will give her a report on the exam. 4. Reassure the parent that you will talk with her about any of her concerns and questions.
The nurse is caring for a patient who is 2 days post-inhalation burn injury from a house fire. Which outcome best indicates that nursing interventions for impaired gas exchange have been effective?
a. Peripheral pulses are present and strong. b. PaCO2 is 56 mm Hg. c. The patient is alert and oriented. d. The patient is afebrile.
A middle-aged parent goes to the emergency room for symptoms of dizziness, headache, and suicidal ideation
The nurse assesses the patient for substance use, employment, child-rearing stressors, relationships with coworkers, recurring physical symptoms, and marital problems. The nurse is: 1. Failing to focus on the seriousness of the primary presenting problem. 2. Establishing rapport that will decrease the likelihood of suicide. 3. Doing more than the nurse's share of the interdisciplinary assessment. 4. Formulating a holistic–interactional assessment needed to interpret clinical data.
Which serious side effect of antipsychotic medications involves sudden fever, rigidity, tachycardia, hypertension, and decreased levels of consciousness?
a. akathisia b. dystonia c. neuroleptic malignant syndrome d. tardive dyskinesia