The nurse assesses an open area over a client's greater trochanter that is approximately 10 cm in diameter. The tissue around the area is edematous, and feels boggy. The edges of the wound cup in toward the center
Which additional finding would indicate to the nurse that this is a stage IV pressure ulcer? A)
There is undermining of adjacent tissues.
B)
The joint capsule of the hip is visible.
C)
The ulcer has thick, dark eschar over the top.
D)
The crater extends into the subcutaneous tissue.
B
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A salesman has had difficulty holding a job because he accuses co-workers of conspiring to take his sales. Today, he argued with several office mates and threatened to kill one of them
The police were called, and he was brought to the mental health center for evaluation. He has had previous admissions to the unit for stabilization of paranoid schizophrenia. When the nurse meets him, he points at staff in the nursing station and states loudly, "They're all plotting to destroy me. Isn't that true?" Which would be the most appropriate response? a. "No, that is not true. People here are trying to help you if you will let them.". b. "Let's think about it: what reason would people have to want to destroy you?" c. "Thinking that people want to destroy you must be very frightening.". d. "That doesn't make sense; staff are health care workers, not murderers.".
The term Web 2.0 has yet to be defined; however, it has been described as consisting of a set of "core characteristics." Which of the following are considered core characteristics? Select all that apply
1. User-centered design 2. Web as platform 3. Collaboration 4. Power decentralization 5. Dynamic content
To assess a patient's jugular veins, the patient should first be placed in which position?
a. Supine b. Semi-Fowler c. Upright d. Left lateral recumbent
What type of breathing will the nurse observe while assessing a patient experiencing both meta-bolic acidosis and Kussmaul respirations?
a. Audible wheezing or stridor b. Increased rate, large tidal volumes, and no expiratory pause c. Rapid respirations with periods of apnea d. Very slow inhalations and rapid expira-tions