A patient in traction with a fractured hip is diagnosed with a stage I pressure ulcer. She asks the nurse how a pressure ulcer could occur after only 2 days of immobility. On what knowledge should the nurse base a response?
a. "Erythema can occur in 1 to 2 hours even in a person with healthy skin and adequate circulation."
b. "It takes several days for a pressure ulcer to form."
c. "The pressure ulcer probably occurred when you fell."
d. "The cause of pressure ulcers isn't really known."
A
Because of impaired blood flow, capillaries in the area of pressure can become congested, and erythema can occur in 1 to 2 hours.
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A couple has undergone prenatal testing and their fetus has an identified congenital anomaly. What action by the nurse is best?
A. "I know how you feel; my daughter has a cleft lip." B. "I'm sure you will come to love your baby anyway." C. "It is normal for both of you to be afraid, sad, or angry." D. "You are lucky you found out now and can prepare."
A child is seen in the emergency department after being bitten by a squirrel while playing outside. Which discharge instruction to the parents is most important?
A. "Give acetaminophen (Tylenol) for pain." B. "Have the child rest tonight." C. "Keep the wound clean and dry." D. "Return here in 3 days."
For a client with obstructive pulmonary disease, nursing care includes diagnoses, outcomes, and interventions for which of the following?
A) Pain C) Activity intolerance B) Atelectasis D) Side effects of medication therapy
Which situation can cause a client to experience "insensible water loss"? Select all that apply.
A. Diarrhea B. Dry, hot weather C. Fever D. Increased respiratory rate E. Nausea F. Mechanical ventilation