The nurse assesses a bed-bound resident, a reddened area over the coccyx that does not blanch is discovered. Which is the best intervention to prevent further skin damage?
a. Cover the site with a transparent film dressing.
b. Apply warm compresses each shift.
c. Turn the patient every 2 hours.
d. Continue to monitor the area.
A
Since this appears to be a stage 1 pressure area, the transparent film ensures the proper amount of moisture is present for healing while allowing monitoring of the area. A warm compress is not warranted. This patient will need to be turned every hour. Monitoring of the area should continue but does not meet the immediate need.
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The nurse is caring for a Vietnamese-American admitted to the intensive care unit as a result of malnutrition. The patient is unable to walk because of his malnutrition,
and he has developed a pressure ulcer from lying in bed constantly without changing positions. The family believes that the patient is depressed and that is why he stopped getting up. When planning this patient's care, the nurse should: a. develop multiple nursing diagnoses. b. develop only one nursing diagnosis to aid in focusing. c. focus on the physical issues facing this patient. d. deal primarily with the patient's psychological needs.
While interviewing the client during the focused interview, the client begins to cry softly. Which of the following interventions by the nurse are appropriate? Standard Text: Select all that apply
1. The nurse states, "It's all right, I think we're done with the interview." 2. The nurse places the tissues within arm's reach of the client. 3. The nurse remains quiet until the nurse feels that the client is prepared to proceed with the interview. 4. The nurse states, "I don't like these questions any more than you do, but we need to get on with the interview so you can go home and cry later." 5. The nurse states, "I can see you are upset. It's all right to cry."
A client comes to the clinic seeking information and education regarding healthy lifestyles and eating habits. Which type of diagnosis should the nurse select for this client?
1. Risk nursing diagnosis 2. Syndrome diagnosis 3. Wellness diagnosis 4. Actual diagnosis
An open wound made by a sharp object is:
a. An incision b. A penetrating wound c. A contusion d. A puncture wound