The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious
Which priority element will the nurse consider when planning care to decrease the development of a decubitus ulcer?
a. Resistance
b. Pressure
c. Weight
d. Stress
ANS: B
Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 15 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance, stress, and weight are not the priority causes of pressure ulcers.
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The nurse is evaluating patients for obesity-related diseases by calculating the waist-to-hip ratios. Which one of these patients would be at increased risk?
a. 29-year-old woman whose waist measures 33 inches and hips measure 36 inches b. 32-year-old man whose waist measures 34 inches and hips measure 36 inches c. 38-year-old man whose waist measures 35 inches and hips measure 38 inches d. 46-year-old woman whose waist measures 30 inches and hips measure 38 inches
Differences between subacute care and long term care include which of the following? (Select all that apply.)
a. Subacute care is more costly than long term care. b. Patients who receive subacute care have a usual length of stay of 1 month; long term care patients have an indefinite length of stay. c. Medicare covers the costs of both sub-acute and long term care. d. Subacute patients tend to be younger and more cognitively intact. e. Subacute care is usually delivered in a hospital setting and long term care in a nursing home setting.
The nurse cautions the homosexual man that his inflamed rectal tissue and rectal tear put him at risk for:
a. an abscess. b. human immunodeficiency virus (HIV) infection. c. hemorrhoids. d. rectal hemorrhage.
The nurse is monitoring a client who has returned to the unit after arterial revascularization. The client reports pain in the affected limb that is similar to the pain experienced before the procedure. What is the nurse's best action?
a. Assess the peripheral pulses in the limb. b. Elevate the affected extremity on pillows. c. Administer pain medication as prescribed. d. Place a warm blanket on the operative limb.