A nurse is assessing a pressure ulcer on the heel of a 75-year-old patient. The nurse notes that the ulcer is deep, extending to the muscle and bone. How would the nurse stage this ulcer?
• Stage IV pressure ulcers: Full thickness skin loss, exposed bone, tendon, or muscle, slough or eschar, and tunneling
• Stage I pressure ulcers: Skin intact, red, non-blanching, warm, painful
• Stage II pressure ulcers: Skin is not intact, loss of the dermis occurs, pink/red, open wound, shallow
• Stage III pressure ulcers: Full thickness skin loss, extends into the dermis and subcutaneous tissue. Slough and tunneling may be present.
A 25-year-old patient was admitted with an injury resulting in a complete C7 transection of the spinal cord. Which action should the nurse anticipate the need for in the immediate post-injury period?
The nurse is assessing a patient with systemic lupus erythematosus (SLE). Which of the following would the nurse expect to note?
While caring for a patient with terminal cancer of the throat, the nurse is approached by the family and is informed that they have already spoken to the physician about taking the patient home. The nurse immediately coordinates discharge planning and informs the family about which supportive service?
The nurse is instructing an American patient with AIDS on how to prevent foodborne illnesses. Due to the patient's immune-compromised state, nurse should instruct the patient to avoid
A palliative care order is written by the physician for a patient with pancreatic cancer. Which of the following physician orders can the nurse anticipate?
The nurse is providing instructions to a patient with a muscle strain of the right biceps femoris. Which of the following instructions should the nurse include?
An elderly patient is scheduled for an MRI. The nurse
A nurse is conducting an hourly neurological assessment on a post-stroke male patient. Upon assessment, the patient only moans and withdraws to pain without opening his eyes. What is his total score in the Glasgow coma scale?
The nurse is caring for a patient who has a carcinoma with no changes in the DNA structure and no viral infections found. What theory of carcinogenesis would this fall under?
A 30-year-old patient has been treated at the emergency department for a head injury and is to be discharged. The nurse explains signs of complications and the appropriate measures to perform if they occur. Which statement by the patient's spouse requires further teaching?
The nurse is assessing an elderly patient suspected of having a fractured left hip after falling onto the ground. The nurse would expect to note which of the following?
A nurse is discharging a patient with multiple sclerosis. The nurse should instruct the patient on which of the following?
A nurse is caring for a patient hospitalized with acute bacterial meningitis. The nurse is teaching a student nurse about acute bacterial meningitis. Which of the following statements indicate that teaching has been ineffective?
The nurse is caring for a patient who was admitted to the hospital with a chief complaint of fatigue and weight loss. The physical examination reveals pallor and multiple bruises on his arms and legs. The results of the patient’s laboratory and diagnostic tests indicate acute lymphocytic leukemia with thrombocytopenia. Which is the appropriate nursing diagnosis?
A patient admitted for a head injury develops dry skin and a urine output of 400 ml/hr. Prioritize the nurse's next actions:
1. Notify the physician.
2. Complete a neuro assessment.
3. Assess the patient's urine specific gravity and blood sodium levels.
4. Start IV fluids and administer desmopressin (DDAVP).
The nurse is assessing a patient suspected of having muscular dystrophy. Which assessment finding is common in all forms and stages of muscular dystrophy?
The nurse is caring for a deteriorating patient going into cardiogenic shock. The nurse expects to note which manifestations?
The nurse is assessing a patient for coronary artery disease (CAD) risk factors. Which of the following modifiable risk factors has the most impact on the development of CAD?
When assessing an 80-year-old client, which of the following physical assessment findings would the nurse report to the physician as concerning?
When performing a breast self-examination, the patient noticed an area that looks like the peel of an orange but with no other changes. The patient decided to call the ambulatory care clinic and informed the nurse about what she found. The nurse should
A patient is admitted to the emergency department with severe frostbite to both feet. Which of the following assessment findings would the nurse expect to see?
The nurse is caring for a patient with Hodgkin's disease who is receiving radiation and chemotherapy. Which statement by the patient indicates they are using a positive coping mechanism during the course of the treatments?
The nurse is assessing a patient with type 1 diabetes mellitus. The patient is confused and light-headed. The nurse should administer
A sedated patient is at risk for the development of pressure ulcers. Which of the following nursing interventions is appropriate for the prevention of pressure ulcers?
A patient has been diagnosed with malignant melanoma. The patient asks the nurse about this type of skin cancer. The nurse provides information, knowing that which of the following is true:
A patient has developed diabetes insipidus after suffering a traumatic brain injury. After treatment has been initiated, the nurse assesses the patient for signs of improvement, including
An intensive care unit (ICU) nurse is providing continuing health education to new nurses in the unit. Which statements made by the nurses are correct?
A 42-year-old patient is admitted to the hospital after sustaining multiple burns. The patient's arm is white, leathery, and does not blanch. Based on this description, what is the depth of injury?
The nurse is caring for a patient with a skeletal muscle disorder. The nurse reviews the patient's lab results and expects which creatine phosphokinase isoenzyme to be elevated?
When caring for a patient with mitral valve stenosis, the nurse should monitor for which of the following symptoms associated with this condition?
The nurse is providing instruction to an older female client who is prescribed furosemide and has episodes of incontinence. Which of the following should the nurse include in the teaching about hydration?
The nurse is caring for a patient diagnosed with infective endocarditis. The patient has a history of intravenous (IV) illicit drug use.
The nurse is reviewing the x-ray of a patient with a fractured tibia. The x-ray shows a fracture diagonal to the bone's long axis. What type of fracture is this?
A nurse is assessing a skin lesion on the back of a 75-year-old patient. The lesion is black and blue, has irregular borders, and is asymmetrical. Based on this clinical description, the most likely diagnosis is:
A nurse knowledgeable about sinoatrial node dysrhythmias would select which of the following causes of sinus tachycardia?
The nurse is reviewing a patient's electrocardiogram (EKG) strip and notes the following: Heart rate of 68, regular rhythm, P waves normal in size and shape, PR interval 0.24 seconds and constant, QRS 0.08 seconds. What will the nurse document for the interpretation of the patient's EKG?
A patient had a colon resection surgery 2 days ago. The patient states that he has not had a bowel movement yet but is passing gas. What should the nurse do?
The nurse is assessing a patient in Thomas splint traction, a device used to immobilize a hip fracture. The nurse should assess for complications as indicated by: