Tissue Intergrity / Mobility / Human Growth and Development

A nurse is teaching a newly hired assistive personnel about working with clients who require assistance with ADLs, which of the following activities. Should the nurse include as an ADL? Toileting Writing Ambulating Talking

Toileting

During a wellness visit for a four-year-old preschooler a patient explains that their child enjoys playing games on a computer and ask the nurse about an acceptable amount of screen time for their child. Which of the following responses to the nurse make? If the child is learning, there are no screen time limits An acceptable amount of screen time is one hour per day If the child is content, there's no protocol for screen time Acceptable screen time is four hours per day

An acceptable amount of screen time is one hour per day

A nurse is discussing climacteric changes that occur during middle adulthood with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the concept? Select all that apply. Both males and females experience a change of life referred to as climacteric Climacteric and females is referred to as menopause Climacteric in males means they are no longer able to fertilize a female egg Climacteric changes in mils of her gradually over a number of years Climacteric in females can manifest as heart palpitations

Both males and females experience a change of life referred to as climacteric Climacteric in females is referred to as menopause Climacteric changes in males occur gradually over a number of years Climacteric and females can manifest as heart palpitations

A nurse is planning an educational session about human growth and development for a group of clients who are pregnant. Which of the following universal principles should the nurse include in the discussion? Select all that apply. Cephalocaudal principle Equifinality principle Simple to complex Continuous process Individualized rates

Cephalocaudal principle Simple to complex Continuous process Individualized rates

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? Obtained the culture using a clean cotton applicator Clean the wound with 0.9% sodium chloride. Collect drainage from the area surrounding the wound Place the applicator in a dry while until cultures are complete

Clean the wound with 0.9% sodium chloride. This versus away any resident bacteria that may be present

A nurse is performing a skin assessment on a client who has a wound on the heel that is blistered and lighter in color and the client skin tone. The nurse should identify that balloon is in which of the following stages of damage. Deep damage through the skin and tissue Damaged beyond the skin layer Damage into the skin layer Damage with the skin intact

Damage into the skin layer In the stage, the wound can be lighter in color than the client skin tone along with temperature differences add an intact or open blister

A nurse is providing discharge, teaching to the caregiver for a client who has a stage one pressure injury to the sacrum, which of the following instructions should be included to the caregiver to prevent further skin breakdown? Be sure to keep the skin moist Do not use pillows to support extremities Flex the client sneeze while in bed Provide a firm mattress for the client

Flex the client sneeze while in bed This takes the pressure off the sacral area and prevents the pliant from sliding down in bed, which can cause shearing and further injury to the skin

A nurse is planning care for a client who is postoperative in which of the following positions to the nurse place the client to prevent atelectasis? Fowlers Lateral Prone Supine

Fowlers The nurse should place the client in Fowlers position to promote long expansion and prevent atelectasis, which is a partial or complete collapsible lung in this position. The client is seated in a semi sitting position I can have their knees bent or straight

A nurse is planning a health class at a local middle school about puberty during adolescence. Which of the following pieces of information should the nurse include in the discussion? Select all that apply. Primary sex organs, mature during puberty Puberty begins with a growth spurt in height and weight One side of puberty is influenced by genetics environment factors, and gender Secondary sex characteristics emerged during puberty Mature ration during puberty occurs at the same rate for everyone

Primary sex organs, mature during puberty Puberty begins with a growth, spurt and height and weight Onset of puberty is influenced by genetics environmental factors and gender Secondary sex characteristics emerged during puberty

A nurse is caring for a client who has a dime size stage one pressure injury, located on the sacrum. Which of the following dressing types to the nurse use? A hydrogel dressing A wet gauze dressing A transparent film An alginate dressing

A transparent film Due to the reduced ability to absorb, moisture, self-adhesive, transfer and dressings are used for covering superficial wound that have minimal exudate

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

A bright pink incision site that is absent of exudate By the seventh postoperative day that the incision site should appear bright, pink and drainage should have subsided

A nurse is completing the Braden scale on for clients were at risk for alterations in skin integrity. Which of the following client should the nurse recognize as having the greatest risk for altered skin integrity? A client who has a Braden scale score of 9 A client who has a Braden scale score of 23 A client who has a Braden scale score of 12 A client who has a breeding scale score of 15

A client who has a Braden scale score of 9 The lowest overall score a client can receive on the Braden scale is a sex with 23 being the maximum score. The lower the overall score of the client receives the greater the risk. The client has it for alterations in skin and tissue. Integrity there for this client has the greatest risk for alterations in skin integrity

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

A client who is incontinent and is taking a prescribed diuretic Clients who are incontinent, have an increased risk for developing alterations in tissue integrity, such as laceration due to prolonged exposure to moisture

A nurse is discussing proper body mechanics with a group of assistive personnel, which of the following information should the nurse include? Select all that apply A staple center of gravity increase a Stability and Balance A wide base lowers the center of gravity Proper body alignment involves tightening the abdomen Leaning slightly back, while carrying an object, equalize the center of gravity Bending at the waist on picking up an object, stabilizes the spine

A staple center of gravity increase a Stability and Balance A wide base lowers the center of gravity Proper body alignment involves tightening the abdomen

A nurse in a long-term care facility is caring for an older client notes. Their muscles have become smaller weaker. Which of the following should the nurse expect the client is experiencing? Sarcopenia Disuse osteoporosis Atrophy Joint contracture

Atrophy Atrophy occurs when the muscles of the body become smaller and weaker. This can occur with prolonged mobility or disuse of a limb

A nurse is caring for a client during a prenatal visit. The client states." now that I'm pregnant I drink wine with dinner. I've given up hard alcohol." Which of the following responses to the nurse make? Avoiding alcohol even wine is advise during pregnancy since it can cause harm to your baby Since you stop drinking hard liquor, your baby will be fine You can drink two glasses of wine each day and not cause harm to your baby You should consume wine with food to minimize its affect on your baby

Avoiding alcohol even wine is advised during pregnancy since it can cause harm to your baby

A nurse is caring for a client who has sustained a gunshot wound to the abdomen and it's six hours post operative. 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? Ask the client to bear down and cough Ask another nurse to bring ice packs to apply to the wound Cover the clients wound with a sterile saline dressing Place the client and high Fowlers position

Cover the clients wound with a sterile, saline dressing

A nurse is caring for a client who had a stroke and is immobile. The nurse should identify that the client is at risk for which of the following conditions? Deep vein, thrombosis Asthma Hernia Hypertension

Deep vein, thrombosis Blood clots can develop when a client is immobile due to an increase in blood, viscosity and atrophy of the muscles. This can result in decrease blood circulation which can lead to blood clots and deep vein thrombosis.

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

Dehiscence Is a separation of part or all of the wound edges. This is a common complication after abdominal surgery, where the client experiences a ripping sensation at the wound site.

A nurse is caring for a six month old infant who has diarrhea. The nurse should monitor the infant for which of the following alterations in tissue integrity? cellulitis skin tears Premature wrinkling Dermatitis

Dermatitis Dermatitis develops when the skin is exposed to urine and feces

A nurse is caring for a client who had a stroke and reports having difficulty with proprioception. The nurse should plan to assess the client for which of the following? Restricted movement due to abnormal fixation of a joint A drop in blood pressure that occurs with a change in position Altered gate with dragging of the toes while ambulating Diminished awareness of body position and balance

Diminished awareness of body position, and Balance Proprioception or kinesthesia is a sense of self awareness and body position. It is a result of feedback from nerve sensory receptors that alert the brain to fine-tune muscle movement in order to regulate balance, coordination and movement.

A nurse is teaching an in-service about the use of economics to a group of staff members. Which of the following information should the nurse include? The use of ergonomically improve blood circulation in the body The use of economics illuminates costs related to Worker's Compensation Do use of economics increases job satisfaction The use of economics mean to use the bodies balance on a lower center of gravity

Do use of Ergonomics Month increases job satisfaction Along with productivity of staff members. When staff members can work safely effectively, they can perform at a higher level.

A nurse is preparing an educational session about school, age children to a group of caregivers. Which of the following characteristics should the nurse include in the teaching? Select all that apply. Attributes feelings and motives to objects Egocentrism decreases Begins to understand reversibility Understands events can be interpreted in different ways Deductive reasoning develops

Egocentrism decreases Begins to understand reversibility Understands events can be interpreted in different ways

A nurse is caring for a client who has a portable wound bulb suction device, and notes that the drainage bulb is 3/4 full. Which of the following actions should the nurse take? Decrease the drainage suction force Place the bulb on a flat surface and measure the amount of drainage Empty and measure the drainage Kink the tubing to prevent further drainage

Empty and measure the drainage The bulb of the portable wound fold suction device should be emptied at least every eight hours or when it is more than half full

A nurse is caring for a 10-year-old child, who is newly diagnosed with diabetes mellitus. Which of the following actions for the child should the nurse recognize as a characteristic of Ericksons stage of industry versus inferiority? Becomes frustrated when their caregiver fills out the child's menu Apologizes to the caregiver for wanting to manage their insulin administration independently States frustration that diabetes mellitus will make them different from everyone else Expresses confidence in their ability to self administer insulin

Expresses confidence in their ability to self administer insulin Industry versus inferiority is Ericksons stage of development occurring during the school age years. During this stage, children work at learning complex skills, problem-solving, and getting a sense of self. Successes in these areas along with support from those around them, promotes a sense of accomplishment and confidence in their endeavors.

A nurse is assessing an adolescent who reports feeling " very depressed". The nurse should recognize that which of the following are signs of increased risk for suicide? Select all that apply. Expressing feelings of gloom and helplessness Expressing lots of interesting activities once considered important Making threats of self harm Having access to weapons Purchasing valued possessions

Expressing feelings of gloom and helplessness Expressing loss of interest in activities, once considered important Making threats of self harm Having access to weapons

A nurse is assessing a clients mobility and notes one of the clients feet drag behind them when ambulating. Which of the following conditions to the nurse suspect the client is experiencing? Atrophy Foot drop Joint contracture Disuse osteoporosis

Foot drop Occurs when the joint of the flight becomes contracted and results in the ability to perform Dorsey flexion or pulling the toes upward. This is due to nerve damage that causes shortening of the muscles. The foot is left with the toes, pointing downward, and in a dropped position.

A nurse is caring for a client who has a deep foot wound with minimal exudate and necrotize tissue. For which of the following dressing types, should the nurse anticipate a prescription to cover the wound? Hydro fiber Alginate Hydrogel Transparent film

Hydrogel Can be used for debridement of wounds with necrotize tissue and eschars and causes minimal trauma to healing wound bed . Hydrogels work differently than other dressings in that they can provide moisture to you, or draw moisture away from the wound, depending upon the needs of the wound.

A nurse is providing prenatal education to a client who is in the first trimester of pregnancy. Which of the following terra tokens should the nurse instruct the client to avoid during pregnancy due to the risk of fetal development? Select all that apply. Chamomile tea Hyperthermia Uncontrolled glucose levels Rubella Smoking

Hyperthermia Uncontrolled glucose levels Rubella Smoking

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? I should consume a diet high in carbohydrates I should increase my protein intake I should include fruit and vegetables with every meal I should avoid meat products

I should increase my protein intake Foods high in protein are essential for wound healing and tissue strengthening. Foods high in omega-3 and omega, six fatty acids and foods with vitamin a and C also aid in wound healing.

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 information? I should expect a small separation along the incision line If I feel like something popped, I should sit up in bed I should report pain at my wound site Recurrent vomiting is expected after surgery

I should report pain at my wound site The client should report picking up the incision site to the nurse. This could be an indication of infection, which can lead to a clients incision to dehiscence

A nurse is caring for adolescence in a school-based health clinic which of the following client statements should the nurse recognize as an indication that the client is experiencing Ericksons stage of identity versus role confusion? I'm coaching a little league team I think I might be gay I can't seem to do anything right for my parents Why would someone want to help me? what's in it for them?

I think I might be gay Identity versus role confusion is the stage of Ericksons theory related to adolescents that involves forming an identity and answering the central question of who am I? Questions about sexuality developing a sense of identity and finding their places society our issues the adolescent addresses during this stage

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

Increased blood glucose

A nurse is performing a focused assessment on an older adult client mobility. Which of the following findings should indicate to the nurse that the client is experiencing an age related changes to the musculoskeletal system? Increase curvature of the thoracic spine Reduce depth perception Narrower stance when standing Quick steps when ambulating

Increased curvature of the thoracic spine The nurse should identify that an increased curvature of the thoracic spine along with protrusion of the neck, indicates an age related changes to the clients musculoskeletal system. This occurs due to bone loss and degeneration of vertebral disc. This can cause a client to lean forward when standing and have an unsteady gait when walking.

A nurse is providing an educational session on cognitive development at a community event. Which of the following statements by the nurse are consistent with Piaget's theory of cognitive development? Select all that apply. Individuals acquired knowledge, intellect, and cognition overtime Intelligence is a natural ability that develops as a child grows and adapt to their environment Children construct knowledge that evolves and changes over time Children construct knowledge in new Waze at critical points during development Adolescence, achieve, formal operational, thought by 16 years of age

Individuals acquired knowledge, intellect, and cognition overtime Intelligence is a natural ability that develops as a child, grows and adapt to their environment Children construct knowledge that evolves in changes over time Children construct knowledge in new ways I critical points during development

A nurse is providing discharge, teaching to parents of a preschooler who was admitted due to a severe, asthma exacerbation. Which of the following instruction should the nurse include? Select all that apply Instruct on the use of metered dose inhaler How family member smoke tobacco products outside of their home Make changes in the home environment to reduce dust mites Share the plan of managing an asthma attack with the child's preschool teachers Decrease fluid intake to prevent exacerbation of asthma

Instruct on the use of a metered dose inhaler How family member smoke tobacco products outside of the house Make changes in the home environment to reduce dust mites Share the plan for managing an asthma attack with the child's preschool teachers

A nurse is providing teaching for a client who has kyphosis. Which of the following information should the nurse include? Kyphosis is when the upper back extends posteriorly to the lower back Kyphosis is an inward curvature of the lower back Kyphosis is a sideways curvature of the spine Kyphosis is a rounded upper back with the pelvis tilted forward

Kyphosis is a rounded upward back with the pelvis tilted forward

A nurse is preparing to transfer a client for me back to a wheelchair. Which of the following actions by the nurse demonstrates proper use of body mechanics? Twisting the torso when transferring the client Bending at the waist when transferring the client Placing the bed in the high position before transferring the client Looking at the client face-to-face when transferring the client

Looking at the client face-to-face when transferring the client This prevents twisting and turning up the tour, so which can cause back injuries

A home health nurse is planning care for an older adult client who has hypertension and is living alone. Which of the following health promotion topics should the nurse include in the clients plan of care? Select all that apply. Maintaining functional capacity Encouraging the use of free-weight exercises Participating in social functions Installing grab bars in the shower Preparing for age related diminished cognition

Maintaining functional capacity Encouraging the use of free-weight exercises Participating in social functions Installing grab bars in the shower

A nurse is caring for a client who requires total assistance with mobility. When using the mobility assessment tool, which of the following pieces of equipment, should the nurse use to transfer at the client? Gait belt Mechanical lift Cane Sit to stand

Mechanical lift

A nurse is caring for a client who requires maximum assistance to transfer from the bed to a chair. Which of the following pieces of equipment should the nurse use? Pivot disc Mechanical lift Sit to stand lift Gait belt

Mechanical lift The nurse should use a mechanical lift, along with assistance from two or more healthcare stuff to transfer a client who is unable to assist do use of a mechanical lift, decreases the risk of injury to both the stuff on the client

A nurse is preparing a poster presentation about the musculoskeletal system. The nurse should include that which of the following is responsible for body posture. Center of gravity Bones Muscles Synovial joints

Muscles Skeletal muscles are attached to the skeleton, they maintain body posture and position

A nurse is preparing a presentation about muscle function for a group of newly licensed nurses which of the following information should the nurse plan to include? Muscle store, calcium and magnesium Muscles produce red blood cells and platelets Muscles assist with thermoregulation in the body Muscles provide protection of internal organs

Muscles assist with thermoregulation in the body Contracting muscles generate heat that assist in maintaining body temperature shivering is an example of the muscles working to produce heat

A nurse is caring for a client who requires assistance with ADLs. Which of the following referrals should the nurse recommend for this client? Speech therapist Physical therapist Respiratory therapist Occupational therapist

Occupational therapist An occupational therapist assess clients who have been paired function to perform ADLs, such as breathing and brushing their teeth

A school nurse asked a first grader about rules at school. The child responds "We need to wash our hands before lunch, Be respectful to the teacher and pay attention in class if we don't want to get into big trouble." The nurse should recognize that the child is in which of the following Kohlberg stages of moral development? Punishment and obedience Good boy nice girl Social contract Law and order

Punishment and obedience The punishment and obedient stage is a part of the first level of Kohlberg's moral development theory, referred to as the preconventional reasoning level and occurs in children between the ages of four and 10 years old. During the punishment and obedience, stage rules are viewed in terms of positive or negative consequences to action. In the punishment and obedient stage rules are all been to avoid punishment. A child who is in the first grade would be in the stage.

A wound ostomy incontinence 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? Pressure injury. Documentation includes the location, stage measurements and conditions of the wound bed and any drainage present. Drainage from a pressure injury only needs to be documented if a foul odor is present If the pressure injury is healing, as expected, documentation can be completed with every other dressing change Pressure injuries found on the mucous membranes should be documented as stage one pressure injuries

Pressure injury. Documentation includes the location, stage measurements and conditions of the wound bed and any drainage present. When documenting pressure injury is the nurse should include the location, stage size description of tissue color of the wound bed condition of surrounding tissues, appearance of wound edges, presence of undermining and tunneling, and any foul odor present. The nurse should also documents the presents and characteristics of any wound drainage observed. Any reports of pain at the wound site should also be documented.

A nurse is caring for a client who has pneumonia. In which of the following positions should the nurse place the client to promote postural drainage? Lateral Supine Prone Fowlers

Prone The nurse should place the client who has pneumonia in the prone position to promote postural drainage. In this position, the client least flat on the abdomen with their head turned to the side.

A nurse is caring for a client who is at risk for developing atelectasis. Which of the following actions should the nurse take? Reposition the client every two hours while in bed Remind the client to use the incentive spirometer Obtain the client weight daily Encourage the client to eat foods that are high in fiber

Remind the client to use the incentive spirometer The nurse should remind the client who is at risk for developing atelectasis to use it in a sentence barometer. Using the incentive spirometer prevents atelectasis from occurring because the client take slow deep breaths to promote lung expansion

A nurse is completing the mobility assessment tool for a client and determines that the client is at level one mobility. The nurse should identify that the client is unable to perform which of the following tasks? Sit on the edge of the bed for one minute Stan in place for five seconds Walk in place Step forward and backward

Sit on the edge of the bed for one minute The client should be able to sit on the edge of the bed for two minutes and extend their arms across their chest to shake hands with the nurse before advancing to the next level, if the client is unable to complete both task to maintain at level one mobility of the MAT

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

Stage three pressure injury to the coccyx observed with full skin loss and visible adipose tissue Characterized by Full thickness, skin loss and visible, adipose, tissue facial muscles tendons bone, ligaments, and cartilage are not visible in the stage

A nurse is preparing to lift a heavy object off the floor. In which order should the nurse perform the following steps to demonstrate the proper use of body mechanics? (place in correct order) Look straight ahead while shoulders raise up Keep abdominal muscles, contract it on the lower back street Stan is close to the object as possible Ben hip slightly and squat Push up for the knees when lifting the object

Stand is close to the object as possible Keep abdominal muscles, contract it on the lower back straight Look straightahead with shoulders raised up Bend hip slightly and squat Push up from the knees when lifting the object

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

Tell the client other side at 30° This prevents the client from sliding down in bed, which can cause sharing on the skin well also relieving pressure to the clients hip

A nurse is providing teaching for a client who injured her ankle. Which of the following information should the nurse include? Cartilage is always remodeling and changing Tendons connect muscle to bone Ligaments are flexible, connective tissue that coat bony areas Synovial joints attached to the skeleton to maintain posture

Tendons connect muscle to bone Tendons and ligaments are both me to fibrous connective tissue. Tendons attach muscle to bone while ligaments attach bones to other bones.

A nurse is observing an assistive personnel care for a client. Which of the following actions by the AP places the client at risk for alterations in skin integrity? The AP places the client in high Fowlers position The AP places pillows under the client lower extremities The AP feeds the client 80% of each meal The AP Cleveland drives the clients perineum after each episode of incontinence

The AP places the client in high Fowlers position

A nurse is evaluating a client who has a broken leg and is using crutches. Which of the following actions by the client demonstrates proper use of the crutches? The hand grips of the crutches are at the level of the clients umbilicus The clients elbows are bent 45° when holding the crutches The client places their weight on their axilla when using the crutches The client has the crutches, resting 5 cm below the axilla

The client has the crutches, resting 5 cm below the axilla The nurse should identify that the client is using the crutches properly when they rest of crutches, 5 cm or 2 inches below the axilla

A nurse is preparing a presentation for a group of clients who are scheduled for joint replacement surgery. Which of the following information should the nurse plan to include regarding flexion of a joint? Synovial joints contains sensory receptors that trigger flexion The contraction of a muscle results inflection of a joint Neurotransmitters coordinate with cartilage to initiate flexion Ligaments extend to enable function of a joint

The contraction of muscles results in fraction of a joint When muscles contract, they shorten and pull against the bone. They are attached to the result is flexion at the joint.

A nurse any 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? The upper dermis contain cells assistance to stomach immune responses Collagen and elastin fibers increase with age The skin consists of four distinct layers The dermis contains blood vessels that help nourish the epidermidis

The dermis contains blood vessels that help nourish the epidermis Dermis is composed of connective tissues, with capillaries blood vessels, and live vessels, which sustain and support the epidermidis by providing strength, flexibility, and nourishment

A nurse is providing teaching to a newly licensed nurse about the functions of the skin. Which of the following statements by the newly licensed nurse, indicates an understanding of the teaching? The skin is strongest, early childhood The epidermidis pads, internal organs and structures The subcutaneous layer of skin contains cells that contribute to skin and color The skin assist in the regulation of body temperature

The skin assist in regulation of body temperature The main functions of the skin, or to provide a barrier from injury, infection and ultraviolet radiation, as well as control fluctuations in body temperature

A nurse is teaching an assistive personal about the skin of older adults. Which of the following statements by the AP indicates an understanding of the teaching? Skin changes caused the synthesis of vitamin B to decrease with age The layers of the skin become detached with age Older adult client to have more moisture in the skin, placing them at risk for maceration The skin of older adults is thinner and has less subcutaneous padding over bony prominences

The skin of older adults us dinner, and has less subcutaneous padding over bony prominences As an individual age is expected changes occur in the skin, including a decrease in elasticities and subcutaneous tissue. This increases the risk of injury to the skin for older adults.

A nurse is teaching a client who is has an unsteady gait about how to use a walker instructions, should the nurse include? The top of the walker should be at the level of your wrist When using the stairs, place to walk her before taking a step When holding the walker, but your elbows 30° Take a step before moving the walker

The top of the walker should be at the level of your wrist This indicates a walker is measured at the appropriate height and prevents straight on the clients back

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 indicates an understanding of an alginate dressing? The dressing will need to be changed every 24 hours This type of dressing is used in small wounds with small amounts of drainage Distressing me, develop a foul smelling yellow gelatinous film on it's under side, as bacteria are trapped This type of dressing will need a secondary dressing for reinforcement

This type of dressing will need a secondary dressing for reinforcements Alginate dressing is not self adhesive and needs a secondary dressing for reinforcement

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

This type of healing begins in the wound bed with the generation of granulation tissue Wound is left open to heal and granulation tissue forms from the bottom up in the wound bed

A nurse is planning discharge teaching for a client who is newly diagnosed with type two diabetes mellitus. which of the following topics should the nurse include in the teaching? Select all that apply. Weight management Low protein diet Glucose testing Daily exercise Foot care

Weight management Glucose testing Daily exercise Foot care

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

You should shift your weight off of your buttocks are intervals throughout the day This action will increase circulation to the tissues and prevent skin breakdown

A nurse is providing teaching to a client about staple removal. Which of the following statements should the nurse include in the teaching? Your staples will dissolve in about four weeks You will need to be placed under general anesthesia for the Staples to be removed Staples are unlikely to becoming better than the skin making removal simple Your staples will be removed in about two weeks

Your staples will be removed in about two weeks In general ones that are closest, Staples heal faster than boys that are sutures. Staples can be removed within 7 to 14 days.