Nokea
The nurse is assessing a hospitalized older client for the presence of pressure ulcers. The nurse notes that the client has a 1" × 1" area on his sacrum in which there is skin breakdown as far as the dermis. What should the nurse note on the chart?
- A. Stage I pressure ulcer.
- B. Stage II pressure ulcer.
- C. Stage III pressure ulcer.
- D. Stage IV pressure ulcer.
Correct Answer: B
Rationale: A Stage II pressure ulcer involves partial-thickness skin loss extending to the dermis, matching the description of the sacral breakdown.
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Which of the following nursing interventions would most likely promote self-care behaviors in the client with a hiatal hernia?
- A. Introduce the client to other people who are successfully managing their care.
- B. Include the client's daughter in the teaching so that she can help implement the plan.
- C. Ask the client to identify other situations in which he demonstrated responsibility for himself.
- D. Reassure client that he will be able to implement all aspects of the plan successfully.
Correct Answer: C
Rationale: Encouraging the client to identify past instances of responsibility promotes self-efficacy and motivates self-care behaviors, which is most effective for long-term management.
A 36-year-old female is complaining of increased vaginal dryness during sexual intercourse. She has received chemotherapy in the past and has menopausal symptoms due to ovarian suppression. An appropriate nursing intervention would be to instruct the client on the use of:
- A. Vaginal dilators.
- B. Nightly douches.
- C. Water-soluble vaginal lubricants.
- D. Relaxation techniques.
Correct Answer: C
Rationale: Water-soluble vaginal lubricants are effective for managing vaginal dryness caused by chemotherapy-induced ovarian suppression, improving comfort during intercourse.
The nurse is caring for a client receiving mechanical ventilation receiving fentanyl and midazolam. Which of the following assessment findings would indicate fentanyl toxicity?
- A. constricted pupils
- B. hypertension
- C. coarse Tremors
- D. diarrhea
Correct Answer: A
Rationale: Constricted pupils (miosis) are a hallmark of opioid toxicity, including fentanyl, due to its effects on the central nervous system.
The nurse finds it difficult to relieve a client's pain satisfactorily. Which of the following measures should the nurse take next when continuing efforts to promote comfort?
- A. Improve the nurse-client relationship.
- B. Enlist the help of the client's family.
- C. Allow the client additional time to work through his or her own responses to pain.
- D. Arrange to have the client share a room with a client who has little pain.
Correct Answer: A
Rationale: Improving the nurse-client relationship fosters trust, enhancing pain management through better communication and tailored interventions. Family help, time, or room sharing are less direct solutions.
The nurse is planning care for a client on complete bed rest. The plan of care should include all except which of the following:
- A. Turning every 2 hours
- B. Passive and active range-of-motion exercises
- C. Use of thromboembolic disease support (TED) hose
- D. Maintaining the client in the supine position
Correct Answer: D
Rationale: Maintaining the client in the supine position is not recommended, as it promotes stasis and pressure ulcers. Turning every 2 hours, range-of-motion exercises, and TED hose prevent complications like thrombophlebitis and skin breakdown during bed rest.