The nurse is monitoring a patient's skin status. Which of these does the nurse recognize as the first sign of prolonged pressure on the skin?
a. Coolness
b. Cyanosis
c. Paleness
d. Redness
ANS: D
Early signs of pressure ulcer formation are warmth, redness, tenderness, and a burning sensation at the potential ulcer site.
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The most significant and overlooked nursing intervention to promote functional ability for an older adult is to
a. Decrease stressors b. Promote fluids c. Ensure safety d. Maintain and improve mobility
Mrs. White, 80 years old, is unable to leave her house, but she has good mobility in her home. The visiting nurse realizes Mrs. White needs some exercise and teaches her to
a. Do 15 push-ups two times a day b. Do a range of motion with a can of soup c. Do deep knee bends d. Do nothing; after all, she is 80 years old and it does not matter
A client prescribed an antidepressant tells the nurse that the pill causes dizziness upon standing or changing position too quickly. The nurse realizes this client is experiencing the most common side effect of which medication?
1. Tricyclic antidepressant 2. Selective serotonin reuptake inhibitor 3. Monoamine oxidase inhibitor 4. Serotonin–norepinephrine reuptake inhibitor
The nurse learns that a family has decided not to accept medical intervention for a health care problem because paying for the care would drastically reduce the family's resources and ability to meet the needs of other family members
Ethically, which of the following actions should be taken by the nurse? a. Appreciate that the family has made the decision that it feels is best and take no further action if it is clear the family has made an informed choice. b. Stress that each individual in society has a right to health care and the family will have to create some way to raise funds for the needed treatment. c. Talk to the media to see whether a campaign to raise funds for the family can be created. d. Try to convince the agency to give the care for free, even if it means economic stress for the agency, because the medical need is obvious.