ch 10 hit II
The initial sign of pressure ulcer is erythema, which normally resolves in less than
1 hour
walker is at the right height when the client's elbows are in which position?
25-degree flexion
normal albumin range
3.4 to 5.4 g/dL. If you have a lower albumin level, you may have malnutrition
When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply. Constipation Edema Sensory overload Anemia Diaphoresis
Anemia, Diaphoresis, edema
functional urinary incontinence
Client does not reach the toilet before experiencing voiding.
ligament
Connects bone to bone
Tendon
Connects muscle to bone
Which explanation demonstrates safe walker use?
Moving the walker, stepping with the affected leg, then stepping with the unaffected leg
which process transforms osteoblasts into mature bone cells?
Ossification and calcification
How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown?
Practice meticulous hygiene measures.
range-of-motion exercise and moves the patient's hand sideways so that the little finger moves toward the forearm
Ulnar deviation
Which nursing intervention will help to prevent contractures?
applying splints
Reflex (neurogenic) incontinence
associated with a spinal cord injury that interrupts cerebral control resulting in no sensory awareness of the need to void
Through which activity does a client learn to consciously contract excretory sphincters and control voiding cues?
biofeedback
cause of erythema
hyperemia
Barthel Index of ADL
measurement tool to determine a patient's level of independence in activities of daily living, such as continence, toileting, transfers, and ambulation
Which therapeutic exercise is done by the nurse without assistance from the client?
passive
air-fluidized surface
protects the skin from moisture
The nurse assesses soft subcutaneous nodules along the line of the tendons in a patient's hand and wrist. What does this finding indicate to the nurse?
rheumatoid arthritis
Braden Scale
sensory perception, moisture, activity, mobility, nutrition, friction and shear
Half of all spinal cord injuries are related to
substance abuse