A nurse assesses a pressure ulcer on a child and finds full-thickness loss of the dermal layer and visible subcutaneous fat. At which stage does the nurse document this pressure ulcer to be?
A.
Stage I
B.
Stage II
C.
Stage III
D.
Stage IV
ANS: C
A stage III pressure ulcer involves the full thickness of the dermis, possible visible subcutaneous fat, possible sloughing, and possible tunneling. This is a stage III ulcer.
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The nurse is developing a nursing care plan for a hospitalized 6-year-old. Which of the following behaviors would warrant nursing intervention?
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A patient is receiving digoxin, 0.25 mg daily. Before giving the medication, the nurse would:
1. count an apical pulse for 15 seconds. 2. hold the dose if the apical rate is 57 beats/min. 3. give the dose if the apical rate is 59 beats/min. 4. double the dose if the rate is 62 beats/min.
A nurse is teaching a client with a new tracheostomy self-care measures and evaluates that teaching goals have been met when the client says
a. "I can shower if I am careful not to get water into the stoma." b. "I don't see why I should quit smoking now; what more could happen?" c. "Stoma covers aren't used because they can lead to suffocation." d. "When my tube comes out I can go swimming again."
The nurse is assessing a client who was recently diagnosed with a meningioma. Which statement indicates that the client correctly understands the diagnosis?
a. "This is the worst type of brain tumor, and surgery is not an option." b. "My tumor can be removed, but I can still have damage because of pressure in my brain." c. "Even after the surgery, I will need che-motherapy to decrease the spread of the tumor." d. "Radiation is never used on brain tumors because of possible nerve damage."