The nurse is caring for a patient and during the assessment, observes a full-thickness 2 cm ? 1 cm skin tear on the right buttock. How should the nurse stage this pressure ulcer?
a. Category I
b. Category II
c. Category III
d. Category IV
C
Category III skin tears have complete tissue loss in which the epidermal flap is missing. Category I skin tears do not have tissue loss. Category II skin tears reflect a partial tissue loss. There is no Category IV.
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The factors that are responsible for the increase in HIV in older adults are
a. Increase in the number of sexual partners b. Performance-enhancing drugs and lack of sex education c. Prevalence of chronic diseases d. None of the above
The nurse is developing a plan of care for a recently admitted client to the medical-surgical unit. Which is the basis for the plan and implementation of the client's care?
1. The nursing diagnosis. 2. The objective data. 3. The subjective data. 4. Client goals.
The nurse determines that the patient with a total laryngectomy has understood the discharge instructions when the patient says:
A) "I can go swimming if I stay in shallow water." B) "I should keep my living area well humidified." C) "I can continue to use powder when I finish my shower." D) "I should cover my stoma with a wool scarf in the winter."
The nurse is preparing a teaching plan for a patient with venous insufficiency and plans to address measures to prevent complications from venous insufficiency. What is one measure the nurse should include in the plan?
A) Avoiding tight-fitting socks B) Reducing activity C) Sleeping with legs dependent D) Avoiding pressure stockings