An RN is assessing an 87-year-old patient who has gone to the clinic to see the health care provider for a follow-up appointment. The nurse notes that the patient looks tired and has dark circles under her eyes
She assesses her skin turgor, which is poor. She is concerned because she knows that poor skin turgor can predispose the patient to which of the following? a. Dehydration
b. Edema
c. Skin breakdown
d. Direct trauma
C
A decrease in turgor predisposes a patient to skin breakdown. Turgor is the skin's elasticity. Normally the skin loses its elasticity with age. Edema or dehydration diminishes turgor. Direct trauma and impairment of venous return are two common causes of edema.
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Fainting is:
a. When the heart and breathing stop without warning b. The sudden loss of consciousness from an inadequate blood supply to the brain c. The excessive loss of blood in a short time d. A condition that results when organs and tissues do not get enough blood
A client is prescribed a hypertonic intravenous solution. Administration of this solution will most likely cause which manifestation to occur?
1. A shift of fluid from the vascular space to the interstitial space. 2. No fluid shift 3. The plasma to have more solutes than the interstitial fluid. 4. The plasma to have fewer solutes than the interstitial fluid
MC Negative pressure wound therapy will not be used for which one of the following clients? Clients with
A. Traumatic wounds. B. Necrotic tissue and eschar. C. Pressure Ulcers. D. Dehisced wounds.
A client has been discharged from the hospital following coronary artery bypass grafting (CABG). The client asks the nurse about the chest pain he experienced prior to coming to the hospital during the heart attack
What instructions should the nurse include in the instructions? A) "If chest pain occurs, rest. If it doesn't go away, take nitroglycerin and report the even to the physician even if the pain is relieved." B) "If chest pain occurs, take a nitroglycerin. If unrelieved, take another one 5 minutes later. If relieved, no further action is required." C) "If chest pain occurs, it may be related to gastritis. Take an antacid and lie down for 30 minutes." D) "You should not have chest pain because you had the CABG, and it fixed the problem with your heart."