A nurse notes that a client's skin is loose, thin, and wrinkled. Which of these skin parameters has the nurse assessed?
a. integrity c. texture
b. moisture d. turgor
C
Skin texture is normally soft and smooth; the nurse should note any variations such as skin that is wrinkled, rough, or scaling.
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An emergency department nurse has just received a call from EMS that they are transporting a 17-year-old male who has just sustained a spinal cord injury (SCI). The nurse recognizes that the most common cause of this type of injury is what?
A) Sports-related injuries B) Acts of violence C) Injuries due to a fall D) Motor vehicle accidents
A client has delivered a stillborn infant at 28 weeks' gestation. Which nursing action is appropriate?
1. Discuss funeral options for the baby. 2. Encourage the couple to try to get pregnant again soon. 3. Ask the couple whether or not they would like to hold the baby. 4. Advise the couple that the baby's death was probably for the best.
During the assessment of a patient with a suspected cardiac tamponade, the nurse should monitor for the development of: Note: Credit will be given only if all correct choices and no incorrect choices are selected. Select all that apply
1. Pulsus paradoxus 2. Muffled heart sounds 3. Hypotension 4. Flat jugular veins
A transfer belt is snug but not too tight if:
a. The person tells you so b. You can slide an open flat hand under the belt c. The person can breathe normally d. The belt buckle is off center