A nurse is treating the pressure ulcer of an African American patient. How would the nurse assess for deep tissue injury in this patient?
A) Upon inspection the nurse would notice a purple or maroon localized area of discolored intact skin.
B) Upon inspection, the nurse would see a blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
C) Upon palpation, the nurse determines that the area preceded by deep tissue injury is painful, firm, boggy, and warmer or cooler as compared with adjacent tissue.
D) Upon inspection the nurse notes partial thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.
C
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A patient has just been diagnosed with Guillain-Barré syndrome and is experiencing ascending, symmetrical muscle weakness and paralysis. Which nursing intervention could best help prevent complications of immobility?
A) Assess strength of neck flexor muscles. B) Promote use of antiembolism stockings. C) Assist with plasmapheresis treatment. D) Administer intravenous immunoglobulin.
What would the nurse teach the diabetic patient to monitor for when beginning a class II antidysrhythmic drug regimen in addition to insulin?
A) Weight loss B) Reduced peripheral perfusion C) Hypoglycemia D) Exercise intolerance
The American Cancer Society recommends that baseline mammograms be performed on women
a. between the ages of 15 and 21. b. between the ages of 35 and 39. c. over 40 years of age. d. over 18 years of age.
The nurse explains that the medically supervised approach to weight reduction will include: (Select all that apply.)
a. medications to suppress the appetite. b. an exercise program. c. participation in a support group. d. stress reduction. e. change in concepts about food.