Your client is alert but elderly, bed-bound, and incontinent and has difficulty eating independently. The client has a wound that is located over a bony prominence and that is not healing well. The wound is most likely to be:
1. Open; a contusion.
2. Contaminated; a penetrating wound.
3. an abrasion; open.
4. a pressure ulcer.
ANS: 4
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When a patient presents with a skin-related complaint, it is important to first:
A. Fully inspect all skin lesions before asking the patient how the lesion in question developed B. Obtain a full history about the development of the skin lesion prior to the physical examination C. Complete a full physical examination of the body prior to inspecting the skin lesion D. Examine the skin lesion without hearing a health history in order to not prejudice the diagnosis
A client is having intraocular pressure measured for both eyes. Which response by the client best indicates that the client understands why this is necessary every year?
a. "Elevated eye pressure can cause high blood pressure." b. "If eye pressure is too high, your eyes will dry out." c. "Elevated eye pressure can press on blood vessels in the eye." d. "Increased eye pressure causes the tear ducts to become blocked."
A client with a diagnosed abdominal aortic aneurysm develops lower back pain radiating to the groin. What is the nurse's interpretation of this information?
A. The aneurysm has become obstructed. B. The aneurysm may be undergoing expansion. C. The client is experiencing inflammation of the aneurysm. D. The client is experiencing normal sensations associated with this condition.
A patient who has benign prostatic hyperplasia (BPH) would like to try an alternative therapy along with the prescribed medication
The nurse would evaluate that education goals have been met when the patient states he will purchase which herbal remedy? 1. Dill weed 2. African star grass 3. St. John's wort 4. Oil of primrose