Foundations Test 3: ATI

A nurse is caring for a client who has the following ABG values: pH 7.44, PaCO2 37 mmHg, HCO3- 24mEq/L. The nurse should identify that these values are an indication of which of the following? A. Metabolic acidosis B. Respiratory acidosis C. Acid-base balance D. Respiratory alkalosis

Acid-base imbalance

A nurse is caring for a client who is experiencing hypovolemia. Which of the following findings should the nurse identify as the priority to report to the provider? a. Dry mucous membranes b. Decreased urine output c. Report of thirst d. Decrease in level of consciousness

Decrease in level of consciousness

A nurse is calculating a clients intake and output for the last 4hr. The client consumed 480mL of water and 240 mL of coffee. The client has also received IV fluids for 4hr infusing at 100 mL/hr. Which of the following amounts represents the clients intake over the last 4hr? a. 1,120 mL b. 720 mL c. 480 mL d. 580 mL

a. 1,120 mL

A nurse is caring for a client who states, "I feel like I don't have to eat a varied diet when I take my multivitamin." Which of the following responses should the nurse make? A. "If taken four or more days a week, a multivitamin provides all the nutrients you need." B. "As long as you take a multivitamin daily, you do not need to eat a varied diet each day." C. "A multivitamin should not be used in place of a nutritious diet." D. "As long as the multivitamin isn't generic, it can replace unhealthy dietary choices."

"A multivitamin should not be used in place of a nutritious diet."

A nurse is caring for a client who states, "I only eat a diet high in protein and carbohydrates." Which of the following responses should the nurse make? a. "Make sure to get enough servings of red meat in your diet daily." b. "Your diet is varied but should also be high in calorie intake." c. "A varied diet should be high in protein and carbohydrate consumption." d. "A nutritious diet should include carbohydrates, protein, fiber, and healthy fats."

"A nutritious diet should include carbohydrates, protein, fiber, and healthy fats."

A nurse is caring for a client who states, "I have been getting a lot of cavities lately, but I don't know what is causing them." Which of the following responses should the nurse make? A. "A lack of protein can cause a problem with cavities." B. "Cavities can be caused by a diet low in vitamin C." C. "Increasing your consumption of leafy green vegetables and tomatoes can help with this." D. "Drinking sugary beverages can make you prone to cavities."

"Drinking sugary beverages can make you prone to cavities."

A nurse is caring for a client who requires a replacement peripheral IV. The client is dehydrated and requires a smaller gauge catheter than the #20 gauge being replaced. Which of the following gauge catheters should the nurse plan to use? a. #16-gauge b. #18-gauge c. #22-gauge d. #14-gauge

#22 gauge

A nurse is discussing macronutrients with a client. Which of the following statements should the nurse make? a. "Macronutrients include vitamins and minerals, which your body needs a large amount of." b. "Macronutrients include carbohydrates, proteins, and fats, which make up the majority of a person's diet." c. "Macronutrients include carbohydrates and fats, which your body needs very little of." d. "While essential, macronutrients should be limited to weekly consumption."

"Macronutrients include carbohydrates, proteins, and fats, which make up the majority of a person's diet."

A nurse is assessing a client who has delirium. Which of the following manifestations should the nurse expect? (Select all that apply.) - Difficulty maintaining attention - Aphasia - Agitation - Alertness - Hallucinations - Rambling speech

- Difficulty maintaining attention - Agitation - Hallucinations - Rambling speech

A nurse is caring for a client who has a new prescription for parenteral nutrition. The client states, "I am scared that I will be on this therapy for the rest of my life." Which of the following responses should the nurse make? a. "There is a good chance you will have to be on this therapy for the rest of your life." b. "Parenteral nutrition is very common and should not interfere with your daily activities." c. "This type of nutrition can be lifelong, but it can also be temporary depending on how your nutritional needs change." d. "I am sure you will need parenteral nutrition temporarily."

"This type of nutrition can be lifelong, but it can also be temporary depending on how your nutritional needs change."

A nurse is caring for a client who has a high phosphorus level. Which of the following instructions regarding food should the nurse provide? a. "You should eat white bread." b. "You can drink 2 cups of milk per day." c. "You should limit broccoli to 3 cups per week." d. "You can have four servings of oatmeal per week."

"You should eat white bread."

A nurse is a caring for a client who has a new prescription for a clear liquid diet. The client asks the nurse, "How long will I have to be on this type of diet?" Which of the following responses should the nurse make? a. "You will be on this diet as long as the provider feels you need to be." b. "You might be on this diet for a week or two." c. "You should not be on this diet for more than a few days." d. "You should speak with the provider about your concern."

"You should not be on this diet for more than a few days."

A nurse is receiving report on four clients. The nurse should identify that which of the following clients might be experiencing hypomagnesemia? a. A client who has vomited four times during the last 8 hr. b. A client who requested an extra breakfast tray to eat. c. A client who can ambulate without assistance. d. A client who reports extreme thirst.

A client who has vomited four times during the last 8hr

A nurse is preparing to assist with feeding a client who is at risk for aspiration. Which of the following actions should the nurse take? a. Position the client upright at a 45° angle. b. Turn on the television per the client's request. c. Avoid allowing the client to drink until meal is finished. d. Cut the client's food into small bites.

Cut the client's food into small bites.

A nurse is reviewing a clients latest ABG report. Which of the following values should the nurse identify as the priority to report to the provider? a. pH 7.37 b. PaCO2 43 mm Hg c. HCO3- 27 mEq/L d. PaO2 76 mm Hg

PaO2 76 mmHg

A nurse is caring for an older adult client who reports unintended weight loss. The client reports that their food does not taste right. The nurse should inform the client that ability to taste which of the following can decrease with age? (Select all that apply.) - Sweet - Salty - Spicy - Bitter - Salty - Savory

Sour Bitter Salty

A nurse is assessing a client's hair and notes that it is brittle. Which of the following should the nurse determine about the client's nutritional intake? A. The client is not getting enough vitamin A. B. The client has insufficient protein in their diet. C. The client needs more vitamin D from sun exposure. D. The client needs to eat five servings of fruits and vegetables daily.

The client has insufficient protein in their diet.

A nurse is caring for a client who has renal disease and must limit potassium intake. Which of the following foods should the nurse instruct the client to avoid because they are high in potassium? (select all that apply) - Apples - Bananas - Dried beans - Spinach - Tomatoes

- Bananas - Dried beans - Spinach - Tomatoes

A nurse is caring for a client who is prescribed a low glycemic index diet. The client states, "I don't understand what this means." Which of the following responses should the nurse make? (Select all that apply.) - "The glycemic index of a food relates to its ability to increase the blood glucose level." - "You should eat foods such as whole grains, fruits, and vegetables." - "Consuming white bread will increase your blood glucose level slowly." - "Try to limit or avoid potatoes due to their high glycemic index." - "Foods with a high glycemic index will cause your blood glucose to increase rapidly."

- "The glycemic index of a food relates to its ability to increase the blood glucose level." - "You should eat foods such as whole grains, fruits, and vegetables." - "Try to limit or avoid potatoes due to their high glycemic index." - "Foods with a high glycemic index will cause your blood glucose to increase rapidly."

A nurse is caring for a client who is nearing the end of life. Which of the following responses by the nurse supports the client's dignity? (select all that apply) - "What would you like to know about your medications?" - "I expect you will feel much better in a few days." - "What can I do to help you feel more independent?" - "I think you should allow your family to make your health care decisions." - "You must be getting tired of lying in bed."

- "What would you like to know about your medications?" - "What can I do to help you feel more independent?"

A nurse is teaching a client about hospice care. Which of the following information should the nurse include? (select all that apply) - "You must have a terminal illness." - "You are eligible for hospice care if you are expected to live for 12 months." - "You can continue treatment to cure your illness." - "You accept palliative care for comfort." - "The health care provider must officially state that you are terminally ill."

- "You must have a terminal illness." - "You accept palliative care for comfort." - "The health care provider must officially state that you are terminally ill."

A nurse is caring for a client whose provider prescribed a heart-healthy diet. Which of the following information should the nurse include for the client regarding heart-healthy diets? (Select all that apply.) - "You should limit saturated fats in your diet." - "You should increase sodium intake to your taste." - "Eat foods with whole grains in your new diet." - "It's important to eat larger portions of fruits and vegetables." - "Limiting high-calorie food intake will promote adherence to your new diet." - "Continue to avoid skim milk and lean meats."

- "You should limit saturated fats in your diet." - "Eat foods with whole grains in your new diet." - "It's important to eat larger portions of fruits and vegetables." - "Limiting high-calorie food intake will promote adherence to your new diet."

A palliative care nurse is preparing an in-service for newly hired staff members about common grief reactions. Which of the following information should the nurse include? (select all that apply) - A client who is grieving often experiences a wide range of emotions. - The anniversary date of a loss should not trigger feelings of sadness after a client has fully accepted the loss. - A client may feel a sense of relief if the death of a loved one was expected. - A client may experience difficulty concentrating and hallucinations as a psychological response to loss. - Behavioral responses to grief can include the refusal to eat or participate in social activities.

- A client who is grieving often experiences a wide range of emotions. - A client may feel a sense of relief if the death of a loved one was expected. - A client may experience difficulty concentrating and hallucinations as a psychological response to loss. - Behavioral responses to grief can include the refusal to eat or participate in social activities.

A nurse is participating in a blood drive and s taking a donation from a client who has type A- Blood. The client asks the nurse what blood types can receive their blood donation. Which of the following responses should the nurse make? (select all that apply.) - A+ - B+ - O+ - AB- - AB+ - A-

- A+ - AB- - AB+ - A-

A nurse is assessing a client for hearing loss. Which of the following findings should the nurse identify as an indication of a possible hearing loss? (Select all that apply.) - Speaks in soft tones - Reports ringing in the ears - Asks for questions to be repeated - Withdraws from social activities - Reports feeling dizzy at times - Describes sounds as being muffled

- Asks for questions to be repeated - Withdraws from social activities - Describes sounds as being muffled

A charge nurse is reviewing Kübler-Ross's 5 stages of grief with a newly licensed nurse. Which of the following statements should the nurse make? (select all that apply) - The five stages occur in a specific order for every client. - Clients might not go through all five stages of grief. - Clients can return to a stage of grief after moving into one of the other stages. - Client who are grieving might attempt to bargain with a higher power. - The stages of grief are only experienced by clients who have a terminal diagnosis.

- Clients might not go through all five stages of grief. - Clients can return to a stage of grief after moving into one of the other stages. - Client who are grieving might attempt to bargain with a higher power.

A nurse is caring for a client whose spouse recently died. The client is from a different culture than the nurse. Which of the following information should the nurse consider when caring for the client? (Select all that apply) - Rituals used to cope with loss are universal across every culture. - Cultural-based rituals can assist clients in handling the death of a loved one. - Culture may determine how a client expresses their grief. - Cultural practices do not dictate the expected length of mourning. - Rituals regarding death direct what procedures are performed on the body after death.

- Cultural-based rituals can assist clients in handling the death of a loved one. - Culture may determine how a client expresses their grief. - Rituals regarding death direct what procedures are performed on the body after death.

A nurse is caring for an older adult client who is experiencing dehydration. The nurse should identify that which of the following factors increases the risk for dehydration in older adult clients? - Decreased kidney function - Decreased thirst response - Decreased total body fluid - Eating watermelon daily - Eating cucumbers with each meal

- Decreased kidney function - Decreased thirst response - Decreased total body fluid

A nurse is providing postmortem care for a client. Which of the following actions should the nurse take? (select all that apply) - Document where the body is being moved. - Include the name of anyone notified in the medical record - document the date and time of death - ensure the clients belongings are accounted for - place an identification tag on a minimum of one area of the clients body.

- Document where the body is being moved. - Include the name of anyone notified in the medical record - document the date and time of death - ensure the clients belongings are accounted for

A nurse is caring for a client who has hearing loss. Which of the following actions should the nurse use to enhance communication with the client? (Select all that apply.) - Provide the client with large print materials. - Ensure the client wears their hearing aids. - Use a sign language interpreter. - Communicate using paper and pen. - Face the client when speaking.

- Ensure the client wears their hearing aids. - Use a sign language interpreter. - Communicate using paper and pen. - Face the client when speaking.

A nurse is reviewing ABG values for a client who is experiencing uncompensated metabolic acidosis. Which of the following ABG values should the nurse expect? - HCO3- 19 mEq/L - pH 7.29 - PaCO2 49 mm Hg - pH 7.49 - PaCO2 35 mm Hg

- HCO3- 19 mEq/L - pH 7.29 - PaCO2 35 mmHg

A nurse is caring for a client for who recently lost their job. Which of the following actions should the nurse take during the assessment step of the nursing process? (select all that apply.) - Identify whether the client is experiencing feelings of grief. - Avoid discussing the client's recent job to prevent upsetting the client. - Check the client for physical manifestations of grief. - Ask the client about their support system. - Provide education about the grief process to the client.

- Identify whether the client is experiencing feelings of grief. - Check the client for physical manifestations of grief. - Ask the client about their support system.

A nurse is caring for client who reports having daily constipation. Which of the following information should the nurse provide to the client regarding fiber intake? (Select all that apply) - Increasing daily fiber intake can help alleviate the issue of constipation. - Eating more whole grains can promote regular bowel movements. - Consume 10 g of fiber per day. - Foods such as white rice increase fiber intake. - Decreasing daily fiber intake can help alleviate digestive discomfort.

- Increasing daily fiber intake can help alleviate the issue of constipation. - Eating more whole grains can promote regular bowel movements.

A nurse is providing discharge teaching to a client who has diabetic neuropathy. Which of the following information should the nurse include? (Select all that apply.) - Inspect the feet every day. - Wear closed-toe shoes. - Install smoke detectors in the home. - Manage glucose levels. - Encourage the client to take their time when speaking.

- Inspect the feet every day. - Wear closed-toe shoes. - Manage glucose levels.

A nurse is preparing to administer medications to a client. Which of the following classifications of medications should the nurse identify as being ototoxic? (Select all that apply.) - Loop diuretics - Benzodiazepines - NSAIDS - Antihistamines - Aminoglycoside antibiotics

- Loop diuretics - NSAIDS - Aminoglycoside antibiotics

A nurse is assessing a client who is experiencing digestive issues. Which of the following findings should the nurse expect? (Select all that apply). - Nausea - Abdominal pain - Diarrhea - Reports of bloating - Reports of excessive salivation

- Nausea - Abdominal pain - Diarrhea - Reports of bloating

A nurse is caring for a client who is receiving treatment for hyponatremia. The nurse should identify that which of the following findings is an indication that the treatment has been effective? - The client states their muscle spasms are absent. - The client reports a headache. - The client denies being confused. - The client reports being nauseated. - The client reports feeling tired.

- The client states their muscle spasms are absent - the client denies being confused

A nurse is caring for a client who is actively dying. The client's caregiver asks the nurse about the client's noisy respirations. Which of the following information should the nurse include? (select all that apply) - They can be an indication of approaching death. - Deep suctioning is effective in removing trapped secretions. - Turning the client's head to the side can assist with drainage. - Medications can be administered to help dry up the secretions. - The client is unable to clear the secretions themselves.

- They can be an indication of approaching death. - Turning the client's head to the side can assist with drainage. - Medications can be administered to help dry up the secretions. - The client is unable to clear the secretions themselves.

A nurse is reviewing the medical history of a client who has conductive hearing loss. The nurse should identify which of the following factors as a potential cause of conductive hearing loss? (Select all that apply.) - Trauma to the outer ear - Damage to inner ear structures - Inflammation - Down syndrome - Cerumen buildup - Otitis media

- Trauma to the outer ear - Inflammation - Cerumen buildup - Otitis media

A nurse is providing teaching about safe ambulation to a client who has vision loss. Which of the following items should the nurse include in the teaching? (Select all that apply.) - A walking cane - Area rugs - A walker - Audio materials - A magnifying glass

- a walking cane - a walker

A nurse is reviewing prescriptions for a client who needs IV fluid replacement therapy due to vomiting and diarrhea. Which of the following fluid prescriptions should the nurse expect to initiate? a. 3% sodium chloride solution b. 0.9% sodium chloride solution c. 0.45% sodium chloride solution d. Dextrose 10% in water

0.9% sodium chloride solution

A nurse is reviewing Kübler-Ross's five stages of grief. The nurse should identify that Kübler-Ross placed the stages in which original order? (place steps in order) Anger Denial Bargaining Acceptance Depression

1. Denial 2. Anger 3. Bargaining 4. Depression 5. Acceptance

A nurse is preparing to administer 4200 mL of IV fluids to a client to infuse over 24hr. The nurse should set the IV pump to deliver how many mL/hr?

175 mL/hr = 4200 mL/24hr

A nurse is preparing to administer 1950mL of .45% sodium chloride IV to infuse over 13hr. The nurse should set the IV pump to deliver how many mL/hr?

1950mL/13hr= 150mL/hr

A nurse is caring for a client who has heart failure and a prescription to receive a unit of packed RBC. The nurse should plan to infuse the blood over which of the following lengths of time? a. 1 hr b. 2 hr c. 4 hr d. 6 hr

4hr

A nurse is helping a client calculate how many net carbohydrates they consumed in their last meal. The client's food had a total of 72 g of carbohydrates and 9 g of fiber. How many net carbohydrates did the client consume? a. 81 b. 63 c. 8 d. 72

63

A charge nurse is discussing hearing tests with a newly licensed nurse. Which of the following information should the charge nurse include? a. The audiometer test measures the brain's electrical activity in response to sounds. b. A tuning fork is placed against the client's mastoid bone during the Rinne test. c. The otoacoustic stimulation (OAE) test is the most commonly performed hearing test. d. Small electrodes are placed behind the client's ears during an electromyography test.

A tuning fork is placed against the client's mastoid bone during the Rinne test.

A nurse is teaching a newly licensed nurse about using the nursing process when caring for a client who has an acid-base imbalance. The nurse should include that the stages of the nursing process should be performed in what order?

Assessment Analysis Planning Implementation Evaluation

A nurse is caring for a client who is scheduled for an otoacoustic emissions (OAE) test. The client asks what to expect during the test. Which of the following responses should the nurse make? A. "You will have small electrodes placed on your scalp during the test." B. "You will have a small probe placed in your ear canal during the test." C. "You will have dye injected through an IV during the test." D. "You will have photographs taken using a special camera during the test."

B. "You will have a small probe placed in your ear canal during the test."

A nurse is providing discharge teaching to the caregiver for a client who has a stage 1 pressure injury to the sacrum. Which of the following instructions should be included to the caregiver to prevent further skin breakdown? a. Be sure to keep the skin moist b. Do not use pillows to support extremities c. Flex the clients knees while in bed. d. Provide a firm mattress for the client.

c. Flex the clients knees while in bed.

A nurse is assessing a client who has been receiving IV therapy for several days and notes that the clients daily weight has increased. The nurse should identify that the client is at increased risk for developing which of the following IV related complications? a. Phlebitis b. Extravasation c. Air embolism d. Circulatory overload

Circulatory overload

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve VIII? A. Monitor for symmetry when the client shrugs their shoulders. B. Ask the client to identify a smell in each nostril. C. Have the client stick out their tongue. D. Whisper something in one ear while occluding the other ear.

D. Whisper something in one ear while occluding the other ear.

A nurse is reviewing the latest arterial blood gas values for a client who is experiencing metabolic alkalosis. The nurse should identify that this action is part of which of the following steps of the nursing process? a. Planning b. Assessment c. Evaluation d. Implementation

Evaluation

A nurse is caring for a client who is experiencing respiratory alkalosis. Which of the following actions should be the goal of treatment for the client? a. Increase the carbon dioxide level. b. Increase the respiratory rate. c. Increase the bicarbonate level. d. Increase the pH level.

Increase the CO2 level

A nurse is caring for a client who has a peripherally inserted central catheter (PICC). For which of the following complications should the nurse monitor? a. The need for multiple IV sticks b. Infection at the access site c. Dehydration d. Infiltration

Infection at the access site

A nurse is caring for a client who is receiving tube feedings via PEG. Which of the following actions should the nurse implement in order to help prevent the client from aspirating? a. Keep the client's head elevated to at least 30° for a minimum of 1 hr after a feeding. b. Verify the initial tube placement with an x-ray after the first feeding. c. Check the client's tube feeding tolerance every 12 hr. d. Check the pH of the gastric contents each day.

Keep the client's head elevated to at least 30° for a minimum of 1 hr after a feeding.

A nurse is preparing to measure a nasogastric tube for insertion. The nurse recalls that the client's xyphoid process should be used as the last place of measurement. Which of the following landmarks should the nurse measure before the xyphoid process? a. Measure from the bottom of the ear. b. Measure from the tip of the chin. c. Measure from the bottom of the jaw line. d. Measure from the tip of the nose to the earlobe.

Measure from the tip of the nose to the earlobe.

A nurse is reviewing the ABG values for a client and notes the following results: pH 7.49, PaCO2 39mmHg, and HCO3- 35 mEq/L. The nurse should interpret this ABG reading as an indication of which of the following acid-base imbalances? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis

Metabolic Alkalosis

A nurse on a pediatric floor is teaching a newly licensed nurse about IV therapy. Which of the following information should the nurse include? a. Perform range of motion exercises on the extremity containing the IV site. b. Shave the client's hair if the IV is to be placed in the scalp. c. IV sites can be placed in the lower extremities up to the age of 2 years. d. Monitor the IV site, tubing, and connections every 4 hr.

Perform range of motion exercises on the extremity containing the IV site

A nurse has completed assessing and analyzing data for a client who has an acid-base imbalance. Which of the following steps of the nursing process should the nurse take next? a. Implementation b. Reassessment c. Evaluation d. Planning

Planning

A nurse is caring for a non-diabetic client who has a new prescription for a fasting blood glucose check. The nurse checks the client's blood glucose and it is 67 mg/dL. Which of the following actions should the nurse take next? a. Document the client's blood glucose level. b. Report the client's blood glucose level to the provider. c. Provide the client with a 15-g carbohydrate snack. d. Recheck the blood sugar in 15 min.

Provide the client with a 15-g carbohydrate snack.

A nurse is reviewing lab results for a client and notes the following ABG values: pH 7.31, PaCO2 49mmHg, HCO3- 25 mEq/L. The nurse should interpret these findings as an indication of which of the following acid-base imbalances? a. Metabolic acidosis b. Respiratory acidosis c. Metabolic alkalosis d. Respiratory alkalosis

Respiratory acidosis

A nurse is caring for a client who routinely eats a regular diet and is scheduled to have surgery with sedation in the morning. The nurse receives a new NPO diet prescription for the client. Which of the following should the nurse identify as the rationale for the provider's prescription? a. The client is at risk for aspiration due to the upcoming surgery. b. The client is at risk for dysphagia due to the upcoming surgery. c. The nutrients consumed as a part of the regular diet will interact with the sedation used in the procedure. d. The client reports having to drink a few sips of water before the procedure.

The client is at risk for aspiration due to the upcoming surgery.

A nurse is reviewing a client's medical record and notes that their BMI is 25.5. How should the nurse interpret this finding? A. The client is overweight. B. The client is underweight. C. The client's BMI is within normal range. D. The client is obese.

The client is overweight

A nurse is assessing a client who is exhibiting signs of fluid and electrolyte imbalance. Which of the following findings should the nurse identify as a potential cause for the clients fluid and electrolyte imbalance? a. The client reports working in a warehouse in 21.1° C (70° F) temperature. b. The client reports that they performed yard work for 8 hr in 35° C (95° F) temperature earlier that day. c. The client reports that their provider decreased their diuretic dose. d. The client reports they had a 24-hr intestinal virus 2 weeks ago.

The client reports that they performed yard work for 8hr in 35 degree celsius (95 degree F) temperature earlier that day

A charge nurse is observing a newly licensed nurse who is preparing to administer a blood transfusion to a client. For which of the following actions by the newly licensed nurse should the charge nurse intervene? a. The nurse selects 0.45% sodium chloride to use to prime the tubing. b. The nurse asks another nurse to check the blood unit label and client identification prior to beginning the transfusion. c. The nurse uses tubing with a filter for the blood transfusion. d. The nurse discards the tubing after the first unit of blood is completed.

The nurse selects .45% sodium chloride to use to prime the tubing

A nurse is caring for a client who has a prescription to receive one unit of packed red blood cells. The client's blood type is AB+, and the nurse receives a unit of A- blood from the blood bank. Which of the following actions should the nurse take? a. Return the blood unit as it is not compatible with the client's blood type. b. Stay with the client for 15 min prior to starting the blood transfusion. c. Verify the unit of blood with another nurse. d. Prime the blood tubing with 0.45% sodium chloride.

Verify the unit of blood with another nurse.

A nurse is discussing the Dual Process Model of Grief with a newly licensed nurse. Which of the following statements should the nurse make? a. "A client's grief will oscillate between loss-oriented grief and restoration-oriented grief." b. "During restoration-oriented grief, a client experiences intense feelings of guilt and sadness about the loved one's death." c. "A client is coping with secondary losses such as loss of income or housing during loss-oriented grief." d. "During loss-oriented grief, a client focuses on rebuilding their future without their loved one."

a. "A client's grief will oscillate between loss-oriented grief and restoration-oriented grief."

A wound, ostomy, and continence nurse (WOCN) is providing an in-service to a group of nurses about documentation of pressure injuries. Which of the following statements by one of the group members indicates an understanding of the teaching? a. "Pressure injury documentation includes the location, stage, measurements, and condition of the wound bed and any drainage present" b. "Drainage from a pressure injury only needs to be documented if a foul odor is present." c. "If the pressure injury is healing as expected, documentation can be completed with every other dressing change." d. "Pressure injuries found on the mucous membranes should be documented as stage 1 pressure injuries."

a. "Pressure injury documentation includes the location, stage, measurements, and condition of the wound bed and any drainage present"

A nurse is performing an admission skin assessment on a client and notes that the client has a stage 3 pressure injury to the coccyx. How should the nurse document the appearance of this pressure injury? a. "Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue." b. "Stage 3 pressure injury to the coccyx observed with a non-blanched area of erythema." c. "Stage 3 pressure injury to the coccyx observed with partial thickness skin loss, wound bed pink and moist." d. "Stage 3 pressure injury to the coccyx observed with full thickness skin loss, muscle and bones visible."

a. "Stage 3 pressure injury to the coccyx observed with full-thickness skin loss and visible adipose tissue."

A nurse is participating in a blood drive and is taking a donation from a client who has type O+ blood. The client asks the nurse what type of blood they can receive. Which of the following statements should the nurse make? a. "You can receive a blood donation from donors with type O- and type O+ blood." b. "You can receive a blood donation from donors with type B- and type A+ blood." c. "You can receive a blood donation from donors with type B- and type AB+ blood." d. "You can receive a blood donation from donors with type AB- and type A- blood."

a. "You can receive a blood donation from donors with type O- and type O+ blood."

A nurse is providing teaching to a client who is in a wheelchair about measures to avoid skin breakdown. Which of the following instructions by the nurse is related to preventing skin breakdown? a. "You should shift you weight off you buttocks at intervals throughout the day." b. "You should be sure your legs are placed on the floor prior to transferring." c. "Position yourself in the back of the wheelchair after transferring." d. "Lack your brakes when you are sitting in the wheelchair."

a. "You should shift you weight off you buttocks at intervals throughout the day."

A nurse is discussing types of grief with a group of clients who have a serious illness. Which of the following formation should the nurse include? a. Anticipatory grief occurs prior to the actual loss of someone or something. b. Normal grief lasts no more than 4 months after a loss has occurred. c. Disenfranchised grief occurs when a client is unable to accept the death of a loved one. d. Prolonged grief is defined as the loss of a relationship that is considered socially unacceptable.

a. Anticipatory grief occurs prior to the actual loss of someone or something.

A nurse is reviewing discharge instructions with a client who has macular degeneration. Which of the following information should the nurse include in the instructions? a. Availability of aids to enhance vision b. Antibiotic therapy c. Risks associated with the loss of peripheral vision d. treatment options

a. Availability of aids to enhance vision

A nurse is preparing to perform a cranial nerve assessment on a client. Which of the following actions should the nurse take to assess cranial nerve II? a. Check the client's visual acuity using a Snellen chart b. Have a client identify specific smells. c. Whisper in one of the client's ears while occluding the other d. Observe for facial symmetry while the client smiles.

a. Check the client's visual acuity using a Snellen chart

A nurse is assisting with the care of a client following abdominal surgery. The nurse removes the client's surgical dressing and notes a separation of the wound edges. The nurse should identify that the client is experiencing which of the following complications? a. Dehiscence b. Evisceration c. Hematoma d. Fistula

a. Dehiscence

A nurse is caring for a client who has a terminal illness and states that they want to experience a "good death" Which of the following actions should the nurse take? a. Determine the client's definition of a "good death." b. Inform the client that culture is irrelevant to an individual's perception of a "good death." c. Inform the client that a "good death" is not possible. d. Communicate with the client that caregivers are prevented from providing a "good death" for the client.

a. Determine the client's definition of a "good death."

A nurse is discussing culturally competent care with another nurse. Which of the following information should the nurse include? a. It is culturally insensitive to talk about impending death in some cultures. b. Most cultures agree with the use of opioids to treat pain. c. A client's cultural information should be obtained from a coworker. d. Culture is irrelevant when a client is making a health care decision.

a. It is culturally insensitive to talk about impending death in some cultures.

A nurse is providing care for a client who has a sensory deficit. Which of the following actions is the nurse's priority for the client? a. Keep the client's environment free from clutter. b. Offer opportunities for the client to get exercise. c. Prevent the client's social isolation. d. Provide nutritional education to the client.

a. Keep the client's environment free from clutter.

A nurse is discussing hospice care services with the caregiver of a client who is terminally ill. Which of the following information should the nurse include? a. Nursing support will be provided in meeting the client's daily needs, including the administration of medications. b. The caregiver can request their terminally ill loved one be admitted to a professional care facility for a maximum of 2 days. c. Nurses are not allowed to become a confidant to the caregiver. d. Nurses will have limited contact with the client and caregiver.

a. Nursing support will be provided in meeting the client's daily needs, including the administration of medications.

A nurse is caring for a middle adult client who asks about expected age-related changes. Which of the following sensory changes should the nurse include as an age-related change? a. Presbyopia b. Diplopia c. Myopia d. Astigmatism

a. Presbyopia

A nurse is assessing a client who is experiencing disenfranchised grief. Which of the following findings should the nurse expect? a. Social isolation b. Verbalization of acceptance of the loss c. Shares feelings of grief with others d. Hypersomnia

a. Social isolation

A nurse is observing an assistive personnel (AP) care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity? a. the AP places the client in high-fowler's position b. the AP places pillows under the clients lower extremities c. the AP feeds the client 80% of each meal d. the AP cleans and dries the client's perineum after each episode of incontinence

a. The AP places the client in high-fowlers position

A nurse has completed the Braden scale on four clients who are at risk for alterations in skin integrity. Which of the following clients should the nurse recognize as having the greatest risk for altered skin integrity? a. a client who has a Braden scale score of 9 b. a client who has a Braden scale score of 23 c. a client who has a Braden scale score of 12 d. a client who has a Braden scale score of 15

a. a client who has a Braden scale score of 9

A nurse is caring for a group of clients. Which of the following clients should the nurse identify as having the highest risk for developing alterations in tissue integrity? a. a client who is incontinent and is taking prescribed diuretic. b. a client who has a lower extremity fracture and uses the overhead bed trapeze to move c. a client who is NPO for surgery and is receiving IV fluids d. a client who has lung cancer and will be receiving their first radiation treatment

a. a client who is incontinent and is taking prescribed diuretic

A nurse is teaching a client who has a pressure injury on their leg about proper nutrition to facilitate wound healing. Which of the following client statements indicates an understanding of the teaching? a. "I should consume a diet high in carbohydrates." b. "I should increase my protein intake." c. "I should include fruit and vegetables with every meal." d. "I should avoid meat products."

b. "I should increase my protein intake."

A charge nurse is discussing sensory processing disorder (SPD) with a newly licensed nurse. Which of the following statements should the charge nurse make? a. "SPD occurs when a client's brain is unable to process rapidly occurring multiple stimuli." b. "SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin." c. "A client is diagnosed with SPD if they experience a significant decrease in stimuli." d. "A client who has SPD has a deficit in the function of one or more of their five senses."

b. "SPD causes clients to be overly sensitive to stimuli, such as the feel of fabric on their skin."

A charge nurse is discussing Worden's Four Tasks of Mourning with a newly licensed nurse. Which of the following statements should the charge nurse include? a. "Accepting the reality of the loss is the third task." b. "The pain of grief is experienced during the second task." c. "The client rearranges their life to live without their loved one during the fourth task." d. "During the third task, a client focuses on remaining connected to their loved one through positive memories."

b. "The pain of grief is experienced during the second task."

A nurse is reviewing the process of how a refraction assessment is performed with a client. Which of the following statements should the nurse make? a. "This test is performed using the Snellen chart." b. "This test is performed using lenses of various prescription strengths." c. "This test is performed by injecting dye into a vein." d. "This test is performed by measuring the amount of pressure inside the eyes."

b. "This test is performed using lenses of various prescription strengths."

A nurse is teaching a newly licensed nurse about wound healing by secondary intention. Which of the following statements by the newly licensed nurse indicated an understanding of healing by secondary intentions? a. "This type of healing carries a lower risk of infection than others." b. "This type of healing begins in the wound bed with the generation of granulation tissue." c. "These wounds heal faster than those that heal by other processes." d. "These wounds require a dry wound bed in order for healing to occur."

b. "This type of healing begins in the wound bed with the generation of granulation tissue."

A nurse is caring for a client who has a terminal illness and reports feeling isolated from family and friends. Which of the following actions should the nurse take? a. Limit visitors to one to two people. b. Assist in scheduling friends and family to visit. c. Discourage face-to-face visits for the client. d. Instruct the client to limit their use of online support groups.

b. Assist in scheduling friends and family to visit.

A nurse is preparing to obtain a wound culture from a client who has a suspected wound infection. which of the following actions should the nurse take? a. Obtain the culture using a clean cotton applicator. b. Clean the wound with 0.9% sodium chloride. c. Collect drainage from the area surrounding the wound. d. Place the applicator in a dry vial until cultures are complete.

b. Clean the wound with 0.9% sodium chloride.

A nurse is caring for a client who has an acid-base imbalance and is experiencing hypoxia. Which of the following actions should the nurse take first? a. Initiate continuous cardiac monitoring. b. Elevate the head of the client's bed. c. Instruct the client to deep breathe and cough. d. Initiate continuous SpO2 monitoring.

b. Elevate the head of the client's bed.

A hospice nurse is caring for a client who is hallucinating and talking to someone who is not there. Which of the following actions should the nurse take? a. tell the client that there is no one there. b. Ensure client safety and prevent injury. c. Decrease verbal interactions with the client. d. Reorient the client to reality.

b. Ensure client safety and prevent injury.

A nurse is caring for an adult client who is mourning the death of a sibling. Which of the following information should the nurse consider when caring for the client? a. Older adult clients tend to experience fewer losses of loved ones. b. Grief differs for adults due to their full understanding of death and memories of the deceased. c. Adults usually do not report physical manifestations associated with experiencing grief. d. Experiencing bereavement is not as common in adults when compared to clients in other age groups.

b. Grief differs for adults due to their full understanding of death and memories of the deceased.

A nurse is teaching a group of older adult clients about the sensory system. The nurse should include that the aging process is most likely to cause which of the following changes? a. Decreased sense of touch b. Hearing loss c. Impaired ability to smell d. Reduced taste

b. Hearing Loss

A nurse is monitoring a client following cholecystectomy. Which of the following findings should the nurse identify as a potential manifestation of sepsis? a. Hypertension b. Increased blood glucose c. Decreased WBC count d. Increased BUN

b. Increased blood glucose

A nurse is caring for a client who is actively dying. The client's caregivers state they are interested in donating the clients organs. Which of the following actions should the nurse take? a. Discuss the process of organ donation with the caregiver. b. Make a referral to an organ procurement organization. c. Inform the caregiver that only the client can give authorization for organ donation. d. Notify the health care provider since they are responsible for discussing organ donation with the family member.

b. Make a referral to an organ procurement organization.

A nurse is discussing palliative care with a client who has colon cancer. Which of the following information should the nurse include? a. Palliative care is limited to a specific time frame. b. Palliative care uses a holistic approach. c. Palliative care is provided after the client has stopped curative treatment methods. d. Palliative care is offered to clients who have non-life-threatening illnesses.

b. Palliative care uses a holistic approach.

A nurse learns that a coworker has died unexpectedly. Which of the following actions should the nurse take? a. Keep personal feelings of grief to themselves. b. Recognize their feelings of grief. c. Attempt to ignore physical manifestations of grief. d. Avoid family and friends when feeling deep sadness.

b. Recognize their feelings of grief.

A charge nurse is preparing an in-service for staff members about spiritual influences on grief. Which of the following information should the nurse include? a. Many religions reject the idea of reincarnation after death. b. Religion can provide comfort during the grieving process. c. Sensitivity to religious beliefs is not a priority in the delivery of client-centered care. d. Spirituality and religious beliefs can hinder post-bereavement outcomes.

b. Religion can provide comfort during the grieving process.

A nurse is planning care for an older client who is bedridden. Which of the following actions should the nurse include in the plan to prevent skin breakdown? a. Firmly massage lotion into the client's skin. b. Tilt the client on their side at 30°. c. Slide the client to the edge of the bed to transfer. d. Keep the head of the bed at 45° when in the supine position.

b. Tilt the client on their side at 30°.

A nurse in an outpatient clinic is assessing the incision site of a client who is 7 days postoperative. Which of the following findings should the nurse expect? a. A red incision with a small amount of exudate b. a bright pink incision site that is absent of exudate c. a pale pink incision site with moderate amounts of exudate d. a white silver incision site absent of exudate

b. a bright pink incision site that is absent of exudate

A nurse is reviewing strategies to reduce the risk of wound dehiscence with a client following abdominal surgery. Which of the following responses by the client indicates an understanding of the informations. a. "I should expect a small separation along the incision line." b. "If I feel like something popped, I should sit up in bed." c. "I should report pain at my wound site." d. "Recurrent vomiting is expected after surgery."

c. "I should report pain at my wound site."

A nurse is caring for a client who states, "My doctor said I should have an EMG. What is that?" Which of the following responses should the nurse make? a. "It is a test that determines if there is a loss of the ability to smell." b. "It is a test that measures the response of the eardrum to various sounds." c. "It is a test that determines if there is nerve damage affecting a muscle." d. "It is a test that is performed to diagnose damage to the retina of the eye."

c. "It is a test that determines if there is nerve damage affecting a muscle."

A nurse is preparing an in-service for a group of staff members about types of tests used to diagnose sensory impairments. Which of the following information should the nurse include? a. An electromyography (EMG) test is performed by placing small electrodes on the scalp. b. A fluorescein angiography test diagnoses dysfunction of the cochlea. c. A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles. d. An Amsler grid test is performed by looking at the internal eye using a slit lamp.

c. A bone oscillator test measures how efficiently sound waves are transmitted through the ossicles.

A nurse is caring for a client who has a dime-sized stage 1 pressure injury located on the sacrum. which of the following dressing types should the nurse use? a. A hydrogel dressing b. A wet gauze dressing c. A transparent film d. An alginate dressing

c. A transparent film

A nurse is caring for a client who has sustained a gunshot wound to the abdomen and is 6hr postoperative. The nurse notices protrusion of the clients organs from the incision site and calls for help. Which of the following actions should the nurse take? a. Ask the client to bear down and cough. b. Ask another nurse to bring icepacks to apply to the wound. c. Cover the client's wound with a sterile saline dressing. d. Place the clients in high-fowlers position

c. Cover the client's wound with a sterile saline dressing.

A nurse is preparing for an initial visit with a client who is experiencing grief. Which of the following tasks should the nurse plan to complete first? a. Provide information to the client about the stages of grief. b. Encourage the client to share thoughts about their loss. c. Develop a relationship with the client. d. Ask the client if they are experiencing physical manifestations of grief.

c. Develop a relationship with the client.

A nurse is caring for a client who is actively dying. Which of the following actions should the nurse take for alterations in breathing pattern? a. Withhold opioids because they can hasten the client's death. b. Report changes in the respiratory pattern to the health care provider as they occur. c. Educate the family about the expected respiratory changes. d. Inform the family that oxygen therapy has no benefit.

c. Educate the family about the expected respiratory changes.

A nurse is caring for a client who has portable wound bulb suction device and notes that the drainage bulb is three-fourths full. Which of the following actions should the nurse take? a. Decrease the drainage suction force. b. Place the bulb on a flat surface and measure the amount of drainage. c. Empty and measure the drainage. d. Kink the tubing to prevent further drainage.

c. Empty and measure the drainage.

A nurse is reviewing hospice care services with a group of newly hired nurses. Which of the following information should the nurse include? a. Hospice services are terminated with the death of the client. b. Hospice services are limited to serving the client. c. Hospice care is an interdisciplinary team effort. d. Hospice care volunteer services are limited to direct client care.

c. Hospice care is an interdisciplinary team effort.

A nurse is reviewing a client's laboratory results. Which of the following results should the nurse report to the provider? a. Potassium 4.5 mEq/L b. Sodium 138 mEq/L c. Magnesium 3 mEq/L d. Calcium 10 mg/dL

c. Magnesium 3 mEq/L

A nurse is grieving following the death of a client who had a terminal illness and is having difficulty sleeping and concentrating. Which of the following actions should the nurse take? a. Avoid talking with more experienced nurses about coping with the death of a client. b. Refrain from attending the client's funeral. c. Participate in an exercise program. d. Distance themselves from the client's family.

c. Participate in an exercise program.

A nurse is caring for a client whose partner recently died. In which step of the nursing process should the nurse and client identify the goals for the clients care? a. Implementation b. Evaluation c. Planning d. Analysis

c. Planning

A nurse is preparing a poster presentation about sensory alterations. Which of the following information should the nurse include about sensory deprivation? a. Sensory deprivation is commonly experienced by clients who are in the ICU. b. Sensory deprivation can cause tactile stimuli to feel painful. c. Risk factors for sensory deprivation include experiencing total vision or hearing loss. d. Sensory deprivation occurs most often in children who have developmental disorders.

c. Risk factors for sensory deprivation include experiencing total vision or hearing loss.

A nurse is assessing a school-age child friend recently died. Which of the following findings should the nurse expect? a. The child believes that their friend's death is temporary. b. The child clings to people. c. The child holds back their feelings. d. The child thinks they are to blame for their friend's death.

c. The child holds back their feelings.

A nurse is planning care for a client who is terminally ill and speaks a different language that the nurse. Which of the following actions should the nurse take? a. Use a family member as a translator. b. Allow an assistive personnel (AP) to translate for the client. c. Use the health care facility's interpreter services. d. Download a smartphone application from the internet.

c. Use the health care facility's interpreter services.

A nurse is caring for a client ho has a deep foot wound with minimal exudate and necrotized tissue. For which of the following dressing types should the nurse anticipate a prescription to cover the wound? a. hydrofiber b. alginate c. hydrogel d. transparent film

c. hydrogel

A nurse is providing teaching to a newly licensed nurse about functions of the skin. Which of the following statements by the newly licensed nurse indicated an understanding of the teaching? a. "The skin is the strongest during early childhood." b. "The epidermis pads internal organs and structures." c." The subcutaneous layer of the skin contains cells that contribute to skin and hair color." d. "The skin assists in the regulation of body temperature."

d. "The skin assists in the regulation of body temperature."

A nurse is teaching an assistive personnel (AP) about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching? a. "Skin changes cause the synthesis of vitamin B to decrease with age." b. "The Layers of the skin become detached with age." c. "Older adult clients have more moisture in the skin, placing them at risk for maceration." d. "The skin of older adults is thinner and has less subcutaneous padding over bony prominences."

d. "The skin of older adults is thinner and has less subcutaneous padding over bony prominences."

A nurse is using the NURSE mnemonic while speaking with a client who is experiencing grief. Which of the following responses by the nurse demonstrates the concept represented by the "U" in the NURSE mnemonic? a. "What is the most challenging aspect for you at this time?" b. "I am going to be here for you all night." c. "It sounds like you may be feeling overwhelmed." d. "There is a lot going on right now, how can I be of help to you?"

d. "There is a lot going on right now, how can I be of help to you?"

A nurse is providing teaching for a client who has a prescription for an alginate dressing for a wound. Which of the following statements by the client indicated an understanding of an alginate dressing? a. "The dressing will need to be changed every 24 hours." b. "This type of dressing is used in small wounds with small amounts of drainage." c. "This dressing may develop a foul-smelling, yellow, gelatinous film on its underside as bacteria are trapped." d. "This type of dressing will need a secondary dressing for reinforcement."

d. "This type of dressing will need a secondary dressing for reinforcement."

A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching? a. "Your staples will dissolve in about 4 weeks." b. "You will need to be placed under general anesthesia for the staples to be removed." c. "Staples are unlikely to become embedded in the skin, making removal simple." d. "Your staples will be removed in about 2 weeks."

d. "Your staples will be removed in about 2 weeks."

A nurse is caring for a client who is actively dying and is discussing pain management with the client's caregiver. Which of the following information should the nurse include? a. Pain control begins with the use of opioids. b. The use of non-pharmacological interventions is contraindicated. c. The use of pain medications can prolong the client's death. d. A combination of approaches is suggested to manage pain symptoms.

d. A combination of approaches is suggested to manage pain symptoms.

A nurse is reviewing the medial record of a client who reports recent anosmia. The nurse should identify which of the following conditions as a risk factor for developing anosmia? a. Gastroesophageal reflux disease b. Herniated lumbar disc c. Wernicke's aphasia d. Alzheimer's disease

d. Alzheimer's disease

A nurse is caring for a client who was diagnosed with chronic kidney disease. The client asks the nurse, "Why me? This is not fair." The nurse should identify the client's statement as an expression of which of the following stages of grief? a. Denial b. Depression c. Bargaining d. Anger

d. Anger

A nurse is preparing to start an IV for a client who has a high risk for bleeding. Which of the following actions should the nurse take? a. Apply a cold compress to the selected IV site. b. Ask the client to hold the extremity up prior to searching for an IV site. c. Ask the client to spread the fingers of the selected extremity. d. Apply a blood pressure cuff set to 30 mm Hg.

d. Apply a blood pressure cuff set to 30 mm Hg.

A nurse is assessing a client whose family is concerned that the client has developed dementia. Which of the following findings should the nurse identify as a manifestation of dementia? a. Rapid-onset memory loss b. Hyperglycemia c. Hypervigilance d. Difficulty problem-solving

d. Difficulty problem-solving

A nurse is caring for a client who reports decreased peripheral vision. The nurse should identify this as a manifestation of which of the following visual impairments? a. Diabetic retinopathy b. Macular degeneration c. Cataract d. Glaucoma

d. Glaucoma

A nurse is assessing a client who is getting divorced and reports feelings of loss associated with no longer being in the role of a spouse. The nurse should identify that the loss of a previously held role is which of the following types of losses? a. Loss of autonomy b. Loss of dreams and expectations c. Loss of safety d. Loss of identity

d. Loss of identity

A nurse is discussing the benefits of palliative care with a newly licensed nurse. Which of the following information should the nurse include? a. Palliative care is offered to clients whose cancer has been in remission for 5 years. b. Palliative care will increase the client's time spent in the health care facility. c. Palliative care reduces client satisfaction. d. Palliative care improves the client's quality of life.

d. Palliative care improves the client's quality of life.

A nurse is discussing the concept of spirituality with a newly licensed nurse. Which of the following information should the nurse include? a. Spirituality can be easily defined. b. Spirituality is similar for all clients. c. Religion and spirituality are interchangeable. d. Spirituality focuses on the significance and purpose of life.

d. Spirituality focuses on the significance and purpose of life.

A nurse is assessing a 16-year-old client whose parent recently died. Which of the following findings should the nurse expect? a. The client is still developing an understanding of death. b. The client feels that "everyone understands me." c. The client can easily express their emotions. d. The client displays high-risk behaviors.

d. The client displays high-risk behaviors.

A nurse in a dermatology clinic is developing a skin anatomy poster to display for clients. which of the following information should the nurse plan to include on the poster? a. The epidermis contains cells that assist in systemic immune responses. b. Collagen and elastin fibers increase with age. c. The skin consists of four distinct layers. d. The dermis contains blood vessels that help nourish the epidermis.

d. The dermis contains blood vessels that help nourish the epidermis.

A nurse is caring for a client who is actively dying and notes the client's feet are purple and marbled. Which of the following findings should the nurse expect? a. the client's feet are warm to the touch. b. the client feels pain in the affected extremities. c. the client has a fever d. mottling is visible on the client's legs.

d. mottling is visible on the client's legs.

A nurse is caring for a 6-month-old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity? a. cellulitis b. skin tears c. premature wrinkling d. dermatitis

d.dermatitis