The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is
a. Pressure.
b. Resistance.
c. Stress.
d. Weight.
ANS: A
Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance (the ability to remain unaltered by the damaging effect of something), stress (worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major causes of pressure ulcers.
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A young boy has just returned home from his family's tropical vacation and is now complaining of worsening tenderness in his right ear. He is subsequently diagnosed with otitis externa
What causative factor of this infection should the nurse suspect? A) Immunocompromised state resulting from sleep deprivation while on vacation B) The potential for foodborne pathogens ingested while on vacation C) Frequent swimming and water sports while the boy was on vacation D) Ear trauma related to pressurization and depressurization while flying
Why is the relaxation phase between contractions important?
a. The laboring woman needs to rest. b. The uterine muscles fatigue without relaxation. c. The contractions can interfere with fetal oxygenation. d. The infant progresses toward delivery at these times.
What marks the end of the third stage of labor?
a. Full cervical dilation b. Expulsion of the placenta and membranes c. Birth of the infant d. Engagement of the head
A patient with pancreatitis is complaining of pain at a level of 10 on a scale of 0 to 10 . The doctor has ordered IV fentanyl citrate (Sublimaze) every 4 hours prn for pain and lorazepam (Ativan) every hour prn for agitation
The last dose was given 3 hours ago. The patient's respiratory rate is 22 per minute with full depth. What is the best nursing action? A) Obtain an order for meperidine (Demerol) to prevent sphincter of Oddi spasm. B) Administer IV fentanyl now, as the patient is in pain. C) Administer IV lorazepam for agitation. D) Consult the physician for an increase in fentanyl frequency.