The nurse is providing care for a 90-year-old patient whose severe cognitive and mobility deficits result in the nursing diagnosis of risk for impaired skin integrity due to lack of mobility
When planning relevant assessments, the nurse should prioritize inspection of what area?
A) The patient's elbows
B) The soles of the patient's feet
C) The patient's heels
D) The patient's knees
Ans: C
Feedback:
Full inspection of the patient's skin is necessary, but the coccyx and the heels are the most susceptible areas for skin breakdown due to shear and friction.
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A mother is concerned about what might have caused a heat rash on her infant. The nurse observes tiny pinhead-sized reddened papules on the infant's neck and axilla. What does the nurse explain as the most likely cause of this rash?
a. Sun exposure b. Allergic reaction c. Infection d. Heat and moisture
A student nurse is working in the OB clinic as part of a preceptorship. The student is counseling a woman in her first trimester who complains of insomnia due to nasal congestion
Which action by the student warrants intervention by the student's preceptor? A. Advises the woman to use over-the-counter nasal saline spray B. Assesses the patient for other allergy and cold symptoms C. Instructs the woman to use decongestants and antihistamines D. Suggests the woman take a hot, steamy bath at bedtime
The nurse is educating a young woman newly diagnosed with genital herpes. Which information is most important for the nurse to include in the teaching plain?
a. Take the entire course of antibiotics. b. Increase fluid intake to dilute urine. c. Wash hands after applying topical oint-ment to lesions. d. Avoid all sexual contact until lesions completely resolve.
MC Standards of nursing practice are best defined as:
A. Authoritative statements describing the nurses' accountability and responsibility. B. Standards that ensure that nursing procedures are the same in all states. C. Guidelines for ethical practices. D. Statements that identify the nurses' role in providing care.