The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage
a. I.
b. II.
c. III.
d. IV.
ANS: B
This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.
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The pediatric nurse describes the effects of cystic fibrosis on the body systems to the parents of a child recently diagnosed with the disease. Which statements does the nurse include to the parents? (Select all that apply.)
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An interpreter asks the nurse, "What is cholesterol?" while helping the nurse communicate with a patient. Which of the following should the nurse do?
a. explain what cholesterol is b. ask the interpreter why they want to know c. ignore the interpreter's question d. tell the interpreter later what cholesterol is
The nurse is discharging a 15-year-old first-time mother. Which statement should the nurse include in the discharge teaching?
A. "Call your pediatrician if the baby's temperature is below 98° F." B. "Your baby's stools will change to a golden color when your milk comes in." C. "You can wipe away any eye drainage that may form." D. "Your infant should wet a diaper at least six times per day."
A nurse is assessing an 11-month-old infant and notes that the infant's height and weight are at the 5th percentile on the growth chart
Family history reveals that the infant's two siblings are at the 50th percentile for height and at the 75th percentile for weight. Psychosocial history reveals that the parents are separated and are planning to divorce. Which of these nursing diagnoses takes priority? 1. Alteration in Growth Pattern Related to Parental Anxiety 2. Alteration in Growth Pattern Secondary to Familial Short Stature 3. Nutritional Intake: Excessive Secondary to Maternal Feeding Patterns 4. At Risk for Constitutional Growth Delay Related to Decreased Appetite