A nurse knows that when skin slides over another surface in the opposite direction, it can cause abrasions and open skin areas, which is known as
1. Shearing.
2. Peristalsis.
3. Atelectasis.
4. Deep vein thrombosis (DVT).
ANS: 1
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The client has delivered a 4200 g fetus. The physician performed a midline episiotomy, which extended into a third-degree laceration. The client asks the nurse where she tore. Which response is best?
1. "The episiotomy extended and tore through your rectal mucosa." 2. "The episiotomy extended and tore up near your vaginal mucous membrane." 3. "The episiotomy extended and tore into the muscle layer." 4. "The episiotomy extended and tore through your anal sphincter."
A patient will be discharged on beta blockers. Which skill is essential for the nurse to teach the patient's family?
a. How to prepare a low-sodium diet b. Assessments to detect fluid retention c. How to monitor heart rate and blood pressure d. Early signs of changing level of consciousness
A client with an infection in his ears visits a healthcare facility. The client wants to know the cause of the infection. Which reason should the nurse identify as the most likely cause of the ear infection in the client?
A) Insertion of a pointed object in the ear B) Infection in the sebaceous gland C) Secretion from the eccrine glands D) Accumulation of cerumen
Which of the following regarding nursing diagnosis are accurate? Select all that apply
a. Provide the basis for nursing interventions b. Are validated with patient and family when possible c. Have historically been well substantiated by research d. Are descriptions of pathological disease processes