The nurse read in the patient's chart that the patient has a stage III pressure ulcer. Which assessment findings are consistent with this stage of ulcer?
a. Damage to the subcutaneous tissue
b. Unblanching skin
c. Presence of mottled skin
d. Damage limited to the epidermis
A
A stage III pressure ulcer presents as a crater-like ulcer. The underlying subcutaneous tissue is involved in the destructive process. The ulcer may or may not be infected. Bacterial infection is almost always present at this stage. Unblanching skin and mottled skin are consistent with a stage I pressure ulcer. Damage to the epidermis is noted with a stage II pressure ulcer.
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The nurse is counseling a 52-year-old male about the risk factors of hypertension. Which of the following should the nurse list as risk factors for primary hypertension?
A) Obesity, high intake of sodium, and saturated fat B) Diabetes mellitus and oral contraceptives C) Metabolic syndrome and smoking D) Renal disease and coarctation of the aorta
A nurse who works in an inner-city clinic provides care for a large number of the older black clients. Which of the following health promotion activities best reflects the particular health needs of this population?
A) A blood sugar and blood pressure monitoring program. B) An education session on the positive health effects of good nutrition. C) A screening mammography campaign for older black women. D) A program that teaches black men the importance of prostate health screening.
The nurse takes every measure to preserve the client's privacy and maintain confidentiality. Which measure should the nurse take with the client to help prevent dehumanization?
A) Develop rapport and trust with the client before delving into personal matters. B) Review the client's condition and treatment plan with family members. C) Avoid telling the client about pending invasive diagnostic tests. D) Emphasize with the client the costs associated with hospitalization.
Which intervention will the nurse perform when monitoring a client receiving triamterene (Dyrenium)?
a. Assess urinary output hourly. b. Monitor for side effect of hypoglycemia. c. Assess potassium levels. d. Monitor for Hypernatremia.