A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy
She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as?
a. Stage II pressure ulcer
b. Stage III pressure ulcer
c. Stage IV pressure ulcer
d. Unstageable pressure ulcer
ANS: D
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The Joint Commission requires which type of assessment be performed on all patients?
1) Functional ability 2) Pain 3) Cultural 4) Wellness
During the focused interview, the client provides information to the nurse regarding her daughter's recent diagnosis with cancer. The client is exhibiting clinical manifestations associated with anxiety
During the physical assessment, which of the following findings might be expected? Standard Text: Select all that apply. 1. The client complains of pain when the tragus is gently manipulated. 2. The client has several small ulcers on her lip. 3. Pale nasal mucosa 4. Small sores are noted within the mouth. 5. Perforated nasal septum
The nurse is preparing to elicit the Babinski reflex on a 6-month-old infant. Which technique should the nurse use?
A. Stroke the plantar surface of the foot from the heel to the toe. B. Turn the infant's head to one side while the infant is supine. C. Hold the infant upright and allow the feet to touch a surface. D. Touch the infant's foot at the base of the toes.
A nurse is performing patient education in anticipation of the client's first treatment with electroconvulsive therapy (ECT). In the process of ECT, what is electricity is used to induce?
A) Temporary brain hypoxia B) Amnesia C) Seizure activity D) Neural reorganization