What should a nurse document when assessing a new pressure ulcer? (Select all that apply.)
a. Precise measurement of the ulcer
b. Location of the wound and its description
c. Color of the ulcer
d. Amount and characteristics of the drai-nage
e. Probable cause of the ulcer
A, B, C, D
Documentation should include the precise location, color, size, shape, and drainage, as well as treatment applications.
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Which of the following are included in the health history of an older adult?
a. Chief complaint b. Amount of edema c. List of medications d. Oculomotor deficits e. Review of the systems f. Current nursing diagnoses
When the values of the nurse and those of the patient are different, the patient may be labeled as which of the following? Select all that apply
a. Noncompliant b. Difficult c. Cooperative d. Ignorant e. Confident
A client is going to receive instruction in biofeedback technique to lower his stress level. The client asks the nurse to describe this technique. What should the nurse tell the client?
A. It is a technique that trains the mind to elicit a relaxation response B. It is the purposeful use of one's imagination to achieve relaxation and control C. It involves learning to contract and relax muscles in a systematic way and may be combined with breathing exercises D. It is a therapeutic modality that enables an individual to monitor skin temperature, muscle activity, heart rate, blood pressure, and other bodily functions, then learn to control these physiologic responses to stressful or challenging events
The nurse is caring for a terminally ill client who recently immigrated to the Canada. To provide quality end-of-life care, what must the nurse do first?
a. Make every effort to involve the client and his or her family in the end-of-life care. b. Understand the client's personal and cultural views regarding death and dying. c. Arrange for end-of-life care to be provided by health care professionals familiar with the client's culture. d. Share the client's concerns regarding the dying process with his or her interdisci-plinary care team.