The client experiences a burn on the arm that is confined to the skin. How should the nurse describe this burn when documenting this client's care?
1. A clean wound
2. A dirty or infected wound
3. A partial-thickness wound
4. A full-thickness wound
3
Rationale 1: There is not enough information provided to know if it is a clean wound.
Rationale 2: There is not enough information provided to know if it is a dirty wound.
Rationale 3: The burn described is a partial-thickness burn if it is confined to the skin or dermis and epidermis.
Rationale 4: TA full-thickness burn involves the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone.
Global Rationale: The burn described is a partial-thickness burn if it is confined to the skin or dermis and epidermis. A full-thickness burn involves the dermis, epidermis, subcutaneous tissue, and possibly muscle and bone. There is not enough information provided to know if it is a clean or dirty wound.
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A patient is given 1 mg of dexamethasone at 11:00 PM; a plasma cortisol level recorded at 8:00 PM the next day is normal. The nurse knows that this is an indication that the patient has what condition?
a. Addison's disease b. Congenital adrenal hyperplasia c. Cushing's syndrome d. Secondary adrenal insufficiency
The nurse is caring for an older patient who has a healed, sacral pressure ulcer. What would the nurse include in teaching about this new tissue growth?
1. "Your sacral area will heal faster if reinjured." 2. "Your skin will break down faster if your sacrum is reinjured." 3. "You may have a loss of feeling in the old, pressure ulcer area." 4. "You are more at risk for infection in the sacral area."
List four components of the stance phase that should be noted when assessing a patient's gait
What will be an ideal response?
The nurse plans to use a goniometer during the physical assessment. Which is assessed using this tool?
1) Extremity length 2) Muscle strength 3) Muscle tension 4) Range of motion (ROM)