The nurse assesses the client's pressure ulcer and notes tissue maceration around the wound. Which does the nurse implement on the affected tissue?
1. Eliminate dead space.
2. Use a barrier ointment.
3. Apply a foam dressing.
4. Obtain a wound culture
2
2. Macerated skin around a wound is consistent with tissue exposure to irritating agents or moisture; thus, the nurse cleanses the area gently and applies a moisture barrier to protect the skin. Although skin needs moisture and a moist environment facilitates wound healing, frequent exposure to moisture or other agents that strip the skin of surface protection increases the risk of skin breakdown.
1. Macerated skin has no dead space.
3. Moderate to heavy exudate is an indication for a foam dressing.
4. A wound culture is not indicated because macerated tissue is not necessarily in-fected.
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The nurse is caring for a patient who has been diagnosed with stage I cancer of the colon. When assessing the need for psychologic support, which question by the nurse will provide the most information?
a. "How long ago were you diagnosed with this cancer?" b. "Do you have any concerns about body image changes?" c. "Can you tell me what has been helpful to you in the past when coping with stressful events?" d. "Are you familiar with the stages of emotional adjustment to a diagnosis like cancer of the colon?"
What is the primary focus of nurse-run clinics?
a. Health promotion b. Disease cure c. Pregnancy counseling services d. Cost control
While assessing the development of a 9-month-old client, the nurse asks the mother if the child actively looks for toys when they are placed out of sight. Which is the nurse assessing with this question to the parent?
1. Transductive reasoning 2. Conservation 3. Centration 4. Object permanence