The nurse is caring for a patient who has undergone external fixation of a broken leg and has a cast in place. To prevent skin impairment, the nurse should
a. Not allow the patient to turn in bed because that may lead to redislocation of the leg.
b. Restrict the patient's dietary intake to reduce the number of times on the bedpan.
c. Assess all surfaces exposed to the cast for pressure areas.
d. Keep the patient's blood pressure low to prevent overperfusion of tissue.
C
Assess all surfaces exposed to casts, cloth restraints, bandages and dressings, tubing, or orthopedic braces. An external device applied to or around the skin exerts pressure or friction on the skin, leading to skin impairment. When restricted from moving, dependent body parts are exposed to pressure that reduces circulation to affected tissues. Know which patients require assistance to turn and change positions. Patients with limited caloric and protein intake develop impaired or delayed wound healing. Keeping the blood pressure artificially low may decrease arterial blood supply, leading to ischemia and breakdown.
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The nurse and client determine that which of the following would be the best long-term goal for the client with a substance dependency? The client will:
1. Promise to abstain from the use of any substance to deal with problems. 2. Identify two acceptable means of solving problems other than substances. 3. Cut substance use in half and gradually decrease it to little or no use. 4. Agree to make restitution to those people who have been harmed.
An 80-year-old man is newly admitted to a long-term care facility and suddenly becomes incontinent of urine at night. What nursing interventions should be used to help restore self-toileting? (Select all that apply.)
a. Waking the resident every 2 hours and escorting him to the bathroom b. Leaving a night-light on c. Discouraging the use of long-legged pa-jama bottoms d. Placing a urinal at the bedside e. Keeping the room uncluttered
Which of the following statements describes a teaching plan?
A) It is required by informal teaching. C) It facilitates reaching goals . B) It results in restoring independence. D) It pertains to optimal time for learning.
A client had surgery yesterday and is complaining of pain. The best action by the nurse is to
a. ask the patient which pain medication she/he took last. b. do a complete assessment of the pain. c. prepare to administer the ordered pain medication. d. record the client's complaints thoroughly and get the pain medication.