While assessing an older patient's stage III pressure ulcer the nurse notes that the wound is beefy red and grainy, and the depth has decreased by 2 mm but the width has not changed. How should the nurse interpret this assessment finding?
1. Not healing properly
2. About to slough off tissue
3. No longer at risk for infection
4. Progressing positively toward healing
4
Rationale: The wound color, texture, and decreasing depth all indicate that the wound is healing properly.
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The nurse is assessing a patient whose body mass index is 23 kg/m2. The nurse would suggest which lifestyle goal for this patient?
1. "To lose weight you should eat a lower fat diet." 2. "You might benefit from additional exercise each day." 3. "Add some calorie and nutrient dense foods to your diet to increase your weight." 4. "Be certain your daily sodium intake does not exceed 2400 mg."
American social interactions are generally considered to be:
a. stylized b. rigid c. respectful d. informal
A cancer patient has developed anticipatory nausea from her chemotherapy for breast cancer. Which drug can help deal with this problem?
1. Loperamide 2. Ranitidine 3. Dronabinol 4. Lorazepam
A nurse assesses a client with a neurologic disorder. Which assessment finding should the nurse identify as a late manifestation of amyotrophic lateral sclerosis (ALS)?
a. Dysarthria b. Dysphagia c. Muscle weakness d. Impairment of respiratory muscles