A patient has a wound that is a shallow crater with surrounding erythema and warmth. What stage pressure ulcer does the nurse chart?
a. Stage I
b. Stage II
c. Stage III
d. Stage IV
B
Stage II is a partial thickness ulcer that looks like an abrasion, blister, or shallow crater. A stage I pressure ulcer is redness or mottled skin that does not blanch. Stage III ulcers are full thickness deep craters. Stage IV ulcers may extend into the fascia and may be necrotic.
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What should the nurse make sure to ask about during the interview? a. Any recent traveling outside the country b. Immunization against influenza c. Method of birth control d. Use of tampons
When planning the care for a client who has a spinal cord injury, the nurse should perform which action first?
1. Testing for motor strength 2. Listening for bowel sounds 3. Palpating the client's bladder for fullness 4. Monitoring the client's blood pressure
The nurse is caring for a 72-year-old female with head and neck cancer who had surgery 2 weeks ago to remove the tumor. She is scheduled to begin external beam radiation therapy 1 week after discharge from the hospital
When discussing the radiation treatment, the nurse understands that it is important to stress: Select all that apply. 1. Getting lots of rest. 2. Meticulous skin care. 3. Protecting the scalp from alopecia. 4. Monitoring blood pressure. 5. Monitoring weight gain.
The client who is scheduled for a biopsy tomorrow is anxious and worried about the results. Which should the nurse do to reduce the client's anxiety and to promote security?
1. Explain all procedures beforehand. 2. Allow the client more time to think. 3. Minimize details the client receives. 4. Administer sedation for severe anxiety.