The nurse admitting an older patient notes a shallow open reddish, pink ulcer without
slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
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, Stage II
partial skin loss involving epidermis and dermis = ulcer
presents clinically as an abrasion, blister, or shallow crater
What is the ability to think and the capacity to learn; the pt is not disoriented or
unable to learn?
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cognitive function
A nurse participating in a research project associated with pressure ulcers will assess
for what predisposing factor that tends to increase the risk for pressure ulcer
development?
a. decreased level of consciousness
b. adequate dietary intake
c. shortness of breath
d. muscular pain
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, a. decreased level of consciousness
patients who are confused or disoriented or who have changing levels of
consciousness are unable to protect themselves. The patient may feel the
pressure but may not understand what to do to relieve the discomfort or to
communicate that he or she is feeling discomfort. Impaired sensory
perception, impaired mobility, shear, friction, and moisture are other
predisposing factors. Shortness of breath, muscular pain, and an adequate
dietary intake are not included among the predisposing factors.
While providing care to a patient, the nurse is responsible, both professionally and
legally, for the appropriateness and proper execution of the care. Which concept
does this describe?
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Accountability
A home health nurse is assembling a puzzle with an older-adult patient and notices
that the patient is having difficulty connecting two puzzle pieces. Which aspect of
sensory deprivation will the nurse document as being most affected?
a. perceptual
b. cognitive
c. affective
d. social
Give this one a try later!
slough on the right heel of the patient. How will the nurse stage this pressure ulcer?
Give this one a try later!
, Stage II
partial skin loss involving epidermis and dermis = ulcer
presents clinically as an abrasion, blister, or shallow crater
What is the ability to think and the capacity to learn; the pt is not disoriented or
unable to learn?
Give this one a try later!
cognitive function
A nurse participating in a research project associated with pressure ulcers will assess
for what predisposing factor that tends to increase the risk for pressure ulcer
development?
a. decreased level of consciousness
b. adequate dietary intake
c. shortness of breath
d. muscular pain
Give this one a try later!
, a. decreased level of consciousness
patients who are confused or disoriented or who have changing levels of
consciousness are unable to protect themselves. The patient may feel the
pressure but may not understand what to do to relieve the discomfort or to
communicate that he or she is feeling discomfort. Impaired sensory
perception, impaired mobility, shear, friction, and moisture are other
predisposing factors. Shortness of breath, muscular pain, and an adequate
dietary intake are not included among the predisposing factors.
While providing care to a patient, the nurse is responsible, both professionally and
legally, for the appropriateness and proper execution of the care. Which concept
does this describe?
Give this one a try later!
Accountability
A home health nurse is assembling a puzzle with an older-adult patient and notices
that the patient is having difficulty connecting two puzzle pieces. Which aspect of
sensory deprivation will the nurse document as being most affected?
a. perceptual
b. cognitive
c. affective
d. social
Give this one a try later!
