Immobility/Skin Integrity Adaptive Quizzing

How many nurses would be required to place a patient in the semi-prone position? A. 1 B. 2 C. 3 D. 4

A. 1 Rationale: Positioning the patient in the Sims position or the semi-prone position would require only one nurse. Positioning the patient in the prone position would require two or three nurses. For logrolling the patient, the assistance of three or four nurses would be required.

The nurse and a patient are talking about a baseball game. Both of them are using the word baseball to refer to the sport. Which best describes the use of the word baseball in this context? A. Denotative B. Connotative C. Intonation D. Metacommunication

A. Denotative Rationale: A word that has the same meaning for all people who speak the same language is considered denotative. The dictionary meaning of the word baseball is denotative. A connotative meaning is influenced by the thoughts, feelings, or ideas of individuals. Intonation refers to the tone of voice. Metacommunication refers to all factors influencing communication.

The nurse notices tension on the face of a patient before going to the operating room. The patient says, "I don't mind going in for surgery." The nurse acknowledges the patient's nonverbal indications of stress and prompts the patient to elaborate on his or her feelings. Which type of communication is the nurse exhibiting? A. Metacommunication B. Nonverbal communication C. Intrapersonal communication D. Nontherapeutic communication

A. Metacommunication Rationale: Metacommunication is a broad term that refers to all factors that influence communication. It involves being aware of influencing factors and helping people understand better what is communicated. Therefore, by acknowledging the patient's nonverbal signs of stress and understanding the situation better, the nurse employs metacommunication. Nonverbal communication involves the five senses and anything that does not involve the spoken or written word; the patient's facial expression is an example of nonverbal communication. Nurses use intrapersonal communication to develop self-awareness and a positive self-esteem that enhances appropriate self-expression. Nontherapeutic communication involves asking personal questions or giving personal opinions, which discourages further expression of patient's feelings and ideas.

The registered nurse is overseeing a nursing student who is providing a dressing change to a patient who had a cesarean section. Which nursing action indicates a need for further learning? A. Choosing a dressing that keeps the periwound moist B. Applying a dressing that controls exudates from the wound C. Cleaning the periwound and wound without applying pressure D. Using sterile normal saline and a sterile gauze to clean the surgical wound

A. choosing a dressing that keeps the periwound moist Rationale: The nurse providing wound care should choose a dressing that keeps the periwound skin dry and the surgical wound bed moist to promote healing. The dressing used for wound care should control exudate from the wound, but it should not desiccate the wound bed. Application of pressure while cleaning the periwound and wound may deepen the wound bed. Using sterile normal saline and a sterile gauze to clean the surgical wound reduces the incidences of infection.

Which critical thinking attitude motivates the nurse to communicate and know more about a patient? A. curiosity B. creativity C. perseverance D. self-confidence

A. curiosity Rationale: Curiosity motivates the nurse to communicate and know more about a patient. Creativity and perseverance are attitudes conducive to communication, because they motivate the nurse to identify innovative solutions. Self-confidence is important, because the nurse who conveys confidence and comfort while communicating can more readily establish an interpersonal caring relationship.

What is the desired outcome when the head of the bead is elevated to 60 degrees in supported Fowler's position? A. improves ventilation B. prevents shoulder dislocation C. relieves the pressure on heels D. prevents hyperextension of knee

A. improves ventilation Rationale: When the head of the bed is elevated to 60 degrees in supported Fowler's position, it improves ventilation. Using a pillow to support the arms would help in preventing shoulder dislocation. Use of heel pressure relief devices would reduce pressure on the heels. Placing a small pillow under the thigh can prevent hyperextension of the knee.

Which positioning aid increases the cervical flexion? A. pillows B. arm splints C. trapeze bars D. trochanter rolls

A. pillows Rationale: When thick pillows are used under the patient's head, it increases cervical flexion. Arm splints help reduce musculoskeletal injuries. A trapeze bar helps patients perform upper arm exercises. Trochanter rolls prevent external rotation of the hips when a patient is in the supine position.

Which position may lead to plantar flexion of the feet ? A. prone position B. supine postion C. side-lying position D. supported Fowler's position

A. prone position Rationale: Placing the patient in the prone position may lead to plantar flexion of the feet. The supine position may increase cervical flexion if a thick pillow is placed below the head. The side-lying position may lead to excessive lateral flexion of the spine. The supported Fowler's position may lead to increased cervical flexion.

Which type of ulcer can be dressed with a transparent of hydrocolloid dressing? A. stage I B. stage II C. stage III D. stage IV

A. stage I Rationale: A stage I pressure ulcer is an intact ulcer that can be dressed with a transparent or hydrocolloid dressing. Composite film, hydrocolloid, and hydrogel dressings are appropriate for stage II pressure ulcers. Hydrocolloid, hydrogen gel covered with foam, calcium alginate, and gauze dressings are appropriate for stage III pressure ulcers. Hydrogel covered with foam, calcium alginate, and gauze dressings are appropriate for stage IV pressure ulcers.

Which activity does the nurse carry out while maintaining a zone of personal space? A. teaching or educating a patient B. making rounds with a physician C. performing a physical assessment D. exchanging patient information at nurses' station

A. teaching or educating a patient Rationale: The nurse maintains varying distances while carrying out different activities. The zone of personal space is 18 inches to 4 feet. The nurse maintains a personal zone while teaching a patient and taking a patient's nursing history. The nurse maintains a social zone, or a distance of 4 to 12 feet, while making rounds with a physician. The nurse enters the intimate zone, a distance of 0 to 18 inches from the patient, when performing physical assessment or when exchanging patient information at the nurses' station in order to protect the patient's privacy in a public area.

The nurse is caring for a 55-year-old patient who is unresponsive. Which communication strategies would be appropriate? Select all that apply. A. Converse only verbally with the patient. B. Call the patient by name during interactions. C. Discuss the patient with others in his presence. D. Provide orientation to person, place, and time. E. Articulate to the patient, as though he or she can hear.

B, D, E Rationale: While the nurse is caring a patient who is unresponsive, the nurse should address the patient by name during communication. The nurse should also orient the patient to place and time. It is important to communicate to the patient in a voice that he or she can hear clearly. It is essential to communicate not only verbally, but also by touch. The nurse should avoid discussing the patient with others in his or her presence.

Which special zone of touch is involved during teeth replacement? A. social zone B. consent zone C. intimate zone D. vulnerable zone

B. consent zone Rationale: The consent zone of touch is a special zone that is involved during tasks such as replacing teeth. This zone requires permission for touching. The social zone is a special zone that does not require permission for touching; it includes the arms, hands, shoulders, and back of patients. The intimate zone is a special zone that requires great sensitivity. The vulnerable zone is a special zone that needs special care.

While positioning a patient in the 30-degree lateral position, the nurse rolls the patient towards his or her side. What is the rationale behind this nursing action? A. Decrease internal rotation B. Decrease trauma to tissues C. Provide comfort to the patient D. Reduce pressure on trochante

B. decrease trauma to tissues Rationale: Rolling a patient toward the nurse side while positioning in a 30-degree lateral position decreases trauma to the tissues. Positioning both arms of the patient in a slightly flexed position decreases internal rotation and adduction of the shoulder. Lowering the head of the bed completely provides comfort to the patient. Placing the nurse's hands under the patient's hips during positioning reduces pressure on the trochanter.

Which phase of the helping relationship is involved when the nurse and a patient meet and become acquainted? A. working phase B. orientation phase C. termination phase D. preinteraction phase

B. orientation phase Rationale: n the orientation phase, the nurse and a patient meet and become acquainted. In the working phase, the nurse and patient work together to solve problems and accomplish goals. In the termination phase, the nurse evaluates goal achievement with the patient and relinquishes responsibility for patient care. In the preinteraction phase, the nurse reviews available data, including medical and nursing history.

The registered nurse is supervising a nursing student who is using positioning aids with a patient. Which nursing action may lead to skin and tissue damage caused by pressure? A. Applying the positioning boots B. Placing a thin pillow under the bony prominences C. Placing the pillow under the knees by slight elevation D. Using rolled washcloths as hand rolls in trochanter rolling

B. placing a thing pillow under the bony prominences

Which position would be beneficial for a patient who is suspected to have lung injury? A. sims position B. prone position C. supine position D. 30-degree lateral position

B. prone position Rationale: Prone position would be beneficial for a patient who is suspected to have lung injury. Sims position would help reduce the risk of foot drop. Supine position would increase the comfort of the patient, thus reducing the risk of injury to the skin and musculoskeletal system. The 30-degree lateral position would be beneficial to a patient who is at risk of pressure ulcers.

The nurse manager calls a meeting of members of the nursing team to resolve problems surrounding patient complaints of slow and sometimes discourteous responses to requests. What role does problem resolution play in this communication? A. Relational context B. Situational context C. Environmental context D. Psychophysiological context

B. situational context Rationale: Situational context involves the reason for communication, which is problem resolution in this instance. Relational context indicates the nature of the relationship among participants, such as a social, helping, or working relationship. Environmental context involves the physical surroundings in which communication occurs. The psychophysiological context involves internal factors affecting communication, such as physiological status and emotional status.

Which stage of the pressure ulcer involves partial-thickness loss of the dermis and manifests as a red-pink, open ulcer without slough? A. stage I B. stage II C. stage III D. stage IV

B. stage II Rationale: A stage II pressure ulcer involves partial-thickness loss of the dermis and manifests as a red-pink, open ulcer without slough. A stage I pressure ulcer presents as intact, nonblanchable, red skin, often over a bony prominence. A stage III pressure ulcer involves full-thickness tissue loss so that subcutaneous fat is visible. A stage IV pressure ulcer involves full-thickness tissue loss extending to and exposing bone, tendon, and/or muscle.

In the communication process, who is the receiver of the message? A. the person who encodes a message B. the person who decodes a message C. the person who delivers a message D. the person who seeks feedback

B. the person who decodes a message Rationale: Communication is an active process between a sender and a receiver. The receiver is the person who receives and decodes a message. The receiver also provides feedback to the sender. The sender is the person who encodes and delivers a message. The sender also seeks both verbal and nonverbal feedback.

Which positioning aid increases cervical flexion? A. thin pillow B. thick pillow C. trapeze bar D. trochanter roll

B. thick pillow Rationale: A thick pillow under a patient's head increases cervical flexion, which is not desirable. Therefore, thin pillows should be placed under the head. A thin pillow under bony prominences does not protect skin and tissue from damage caused by pressure. Therefore, thick pillows should be placed under bony prominences. A trapeze bar allows the patient to pull with the upper extremities to raise the trunk off the bed. The trochanter roll prevents external rotation of the hips when a patient is in a supine position.

Which factors influence the relational context of communication? Select all that apply. A. expression of feelings B. customs and expectations C. balance of power and control D. shared history of participants E. growth and development status

C, D Rationale: Factors of communication that influence the nature of the relationship among participants include the shared history of participants, balance of power, and control. Expression of feelings is a factor related to situational context. Customs and expectations are sociocultural elements that affect an interaction. Growth and development status is the internal factor of communication related to psycho-physiological context.

Which distance of personal space is involved when giving a verbal report to a group of nurses? A. 2 ft. B. 3 t C. 9 ft D. 13 ft

C. 9 ft Rationale: While giving verbal report to a group of nurses, a socio-consultative zone of 9 to 12 feet (274 to 366 cm) is appropriate. While taking a patient's nursing history or teaching an individual patient, a personal zone of 18 inches (46 cm) to 4 feet (122 cm) is followed. While speaking at a community forum, a public zone of 12 feet (366 cm) or more is typical.

The nursing student is performing range-of-motion (ROM) exercises for a patient who has been immobile for an extended period. Which action performed by the nursing student needs correction? A. Performing ROM exercises when the pain score is 2 B. Performing ROM exercises 5 times during a session C. Performing ROM exercises from smaller joints to larger joints D. Performing ROM exercises by extending the joint as much as possible

C. Performing ROM exercises from smaller joints to larger joints Rationale: The nurse should perform the ROM exercises from larger joints to smaller joints. Because a pain score of 0 is not possible, a pain score 2 is considered as a minimum in which ROM exercises can be performed. The movements should be repeated 5 times during each session. The joint can be extended as much as possible, but it should not be extended beyond resistance, and force should not be applied to perform the ROM exercises.

Which aspect of positioning a patient in the supported Fowler's position has a goal of decreasing flexion of vertebrae? A. Place a small pillow under thigh B. Place the head on a small pillow C. Place a small pillow at the lower back D. Place a pillow to support arms and hands

C. Place a small pillow at the lower back Rationale: The nurse should place a small pillow at lower back to decrease flexion of vertebrae. Placing a small pillow under the thigh prevents hyperextension of the knee. Placing the head on a small pillow prevents flexion contractures of cervical vertebrae. Placing a pillow to support the arms and hands prevents shoulder dislocation.

The registered nurse is overseeing a nursing student who is collecting samples of wound drainage for culture. Which nursing action indicates a need for further learning? A. Cleaning a wound with normal saline B. Using a different method of specimen collection for each type of organism C. Collecting wound culture samples from old drainage D. Using a 10-mL disposable syringe with a 22-gauge needle

C. collecting wound culture samples from old drainage Rationale: The nursing student should never collect a wound culture sample from old drainage, because these organisms may not be the organisms that caused the infection. The other actions are correct. Cleaning a wound with normal saline helps to remove skin flora. The nursing student should use a different method of specimen collection for each type of organism. The nursing student should use a 10-mL disposable syringe with a 22-gauge needle to aspirate the wound drainage for culture.

Under the supervision of the registered nurse, the nursing student is repositioning a patient to reduce the risk of pressure ulcers. Which nursing action indicates a need for further learning? A. Teaching the patient to shift his or her weight every 15 minutes B. Encouraging the patient to sleep in a supine position C. Encouraging the patient to sit on a donut-shaped cushion D. Encouraging the patient to place the ischial areas on an air-filled pillow

C. encouraging the patient to sit on a donut-shaped cushion Rationale: Rigid and donut-shaped cushions reduce blood supply to the vulnerable areas, resulting in wider areas of ischemia. Therefore, the patient who is at risk of pressure ulcers should avoid such cushions. The remaining actions are correct. If the patient can shift his or her weight every 15 minutes, this can help prevent pressure ulcers. The pressure on the ischial tuberosities, areas at risk for ulcers, can be reduced to a certain extent by allowing the patient to rest in a supine position. Using a foam, gel, or air cushion can help redistribute weight away from the ischial areas.

While the nurse explains the steps of a procedure to a patient, the patient frequently nods and says, "I see." Which element of the communication process is the patient displaying? A. channel B. referent C. feedback D. interpersonal variabel

C. feedback Rationale: Feedback is the verbal and nonverbal messages that the receiver sends indicating whether or not he or she has understood the sender's message. In this case, the feedback indicates whether the patient has understood the meaning of the nurse's message. Channels of communication are means of sending and receiving messages through different aids, such as visual, auditory, and tactile senses. The referent process helps motivate one person to communicate with the other. Interpersonal variables such as educational, developmental, and socio-cultural background, and values and beliefs are characteristics of both the sender and receiver that influence communication.

According the Braden Scale for predicting pressure ulcer risk, which factor most puts the patient at risk for developing a pressure ulcer? A. dry skin B. walks occasionally C. poor nutrition D slightly limited sensory perception

C. poor nutrition Rationale: Of these factors, the patient's poor nutrition carries the highest risk for the patient developing a pressure ulcer. The better the nutrition, the lower the risk. Moist, not dry, skin puts a patient at a greater risk for developing a pressure ulcer. Although frequent, rather than occasional, activity is ideal for reducing the risk for developing a pressure ulcer, the more immobile the patient is, the greater the chance of pressure ulcer development. Slightly limited sensory perception puts a patient at less of a risk than does very limited or completely limited sensory perception.

What is the role of vitamin A in wound closure? A. quickens fibroplasia B. acts as an antioxidant C. promotes wound closure D. acts as immune function

C. promotes wound closure Rationale: Vitamin A promotes epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation. Protein quickens fibroplasia and acts as immune function. Vitamin C acts as an antioxidant.

While positioning a patient with pressure ulcers, the nurse observes lateral flexion of the neck and an internally rotated shoulder and hip joints. Which patient positioning would have caused the patient's position? A. Prone position B. Supine position C. Side-lying position D. Supported Fowler's position

C. side-lying position Rationale: A 30-degree side-lying position is recommended for patients with pressure ulcers. Some trouble points are common in the side-lying position, such as lateral flexion of the neck and internally rotated shoulder and hip joints. Placing patients in the prone position may cause neck hyperflexion and hyperextension of the lumbar spine. Placing the patient in the supine position may cause extended elbows and externally rotated hips. When the patient is placed in the supported Fowler's position, he or she may suffer from increased cervical flexion and external rotation of the hips.

While caring for a postoperative patient, the nurse spreads trochanter rolls on the bed before positioning the patient. In which position is the nurse preparing to place the patient? A. Sims' position B. Prone position C. Supine position D. Supported Fowler's Position

C. supine position Rationale: Trochanter rolls are used to increase comfort for the patient and to reduce the risk of injury to the skin and musculoskeletal system when the patient is placed in the supine position. In the Sims' position, the patient places the weight on the anterior ileum, humerus, and clavicle. Trochanter rolls would not be used in this position. In the prone position, the nurse uses pillows under the lower extremities to reduce the risk of foot drop. In the supported Fowler's position, the knees are supported to reduce the risk of deep vein thrombosis.

Which nutrient is an antioxidant that promotes wound healing? a. zinc b. protein c. vitamin C d. vitmin A

C. vitamin C Rationale: Vitamin C is an antioxidant that is useful in wound healing by promoting collagen synthesis, capillary wall integrity, fibroblast function, and immunity. Zinc is an essential nutrient that promotes collagen formation, protein synthesis, and cell membrane and host defenses. Proteins support healing with fibroplasia, angiogenesis, collagen formation, and wound remodeling while boosting immunity. Vitamin A supports healing with epithelialization, wound closure, inflammatory response, angiogenesis, and collagen formation.

Which is characteristic of abnormal healing of a primary wound? A. Slough tissue in the wound base B. A fruity, earthy, or putrid odor C. A dry or moist granulation tissue bed D. Drainage for more than 3 days after closure

D drainage for more than 3 days after closure Rationale: If a primary-intention wound has drainage for more than 3 days after closure, this is a sign of abnormal healing. Slough tissue in the wound base, a fruity, earthy, or putrid odor, and a dry or moist granulation tissue bed are signs of abnormal healing of a secondary-intention wound.

The registered nurse is teaching a nursing student about the safety guidelines for nursing skills. Which statement by the nursing student indicates the need for further learning? A. "I should raise the side rail on the opposite side of the bed from where I'm standing." B. I should evaluate the patient for correct body alignment." C. "I should determine the type of assistance required for safe positioning." D. "I should arrange the positioning equipment as close as possible to the patient's bed."

D. "I should arrange the positioning equipment as close as possible to the patient's bed" Rationale: The positioning equipment should be arranged in such a way that it does not interfere with the positioning process; therefore, the equipment should not always be placed next to or too far away from the bed, but should be placed appropriately. The side rails on the side of the bed should be raised on the opposite side where the nurse stands to prevent the patient from falling out of the bed. The nurse should evaluate the patient for correct body alignment and pressure risks after repositioning. The nurse should determine the amount and type of assistance required for safe positioning, including any transfer equipment and the number of personnel to safely transfer the patient.

The nurse is assisting a patient in the supported supine position. Which nursing action should the nurse implement to reduce the rotation of the hip? A. Placing pillows under the upper shoulders B. Placing pillows under the pronated forearms C. Placing small rolled towel under the lumbar area of back D. Placing trochanter rolls parallel to the lateral surface of the thighs

D. Placing trochanter rolls parallel to the lateral surface of the thighs Rationale: While positioning the patient in the supine position, the nurse should place trochanter rolls or sandbags parallel to the lateral surface of the patient's thighs if the patient is immobile. Placing pillows under the upper shoulders, neck, or head helps in maintaining the correct body alignment and prevents flexion contractures of the cervical spine. The nurse places pillows under the pronated forearms and keeps the upper arms parallel to the patient's body to reduce the internal rotation of the shoulder and prevent extension of the elbows. Placing a small rolled towel under the lumbar area of the back provides support to the lumbar region.

What does the term referent mean in the communication process? A. A primary healthcare provider who refers a patient B. A patient who is being referred C. A service to which the patient is being referred D. An event that motivates a person to communicate with another

D. an event that motivates a person to communicate with another. Rationale: A referent is any factor that motivates a person to communicate with others. This can include sights, sounds, odors, emotions, or perceptions that can be the basis for a person to talk with another. The term does not refer to the primaryhealth care provider, the patient, or the service being provided.

Which sign is an early indication of pressure that resolves without tissue loss if the pressure is eliminated? A. pallor or molting B. dark red or purple discoloration C. blanchable erythema D. non-blanchable erythema

D. blanchable erythema Rationale: Blanchable erythema is an early indication of pressure that resolves without tissue loss if the pressure is removed. Pallor or molting is a sign of persistent hypoxia. Dark red or purple discoloration may indicate potential damage to blood vessels and tissue. Nonblanchable erythema is a sign of a stage I pressure ulcer.

The nurse has placed a patient in the Sims' position. Which areas would bear the maximum weight of the body? A. elbow B. knees C. ankles D. clavicle

D. clavicle Rationale: In the Sims' position, the major portion of weight is placed on the clavicle and humerus. Pressure points such as the elbows are unprotected in the supine position. The knees are unprotected pressure points in the prone position. The ankles are unprotected pressure points in the side-lying position.

When cleaning a wound, which action is incorrect? A. Using two separate swabs to clean the affected site B. Irrigating from the least to most contaminated area C. Applying noncytotoxic solutions using gentle friction D. Cleaning from the surrounding skin to the site of incision

D. cleaning from the surrounding skin o the site of incision Rationale: The nurse should clean away from the wound to prevent contamination. Two separate swabs are to be used: one to clean from the top of the incision toward the draining site and another to clean from the bottom of the incision toward the draining site. Irrigation fluid should flow from the least to most contaminated area to prevent transmission of bacteria. Application of pressure while cleaning the wound should be avoided, but gentle friction may be applied while cleaning the traumatic wound with the noncytotoxic solution.

Which nursing action prevents tension on the spinal column and adduction of the hips while logrolling the patient? A. Crossing patient's arms on the chest B. Placing the patient in the supine position C. Rolling a drawsheet alongside of the patient D. Placing small pillows between patient's knees

D. placing small pillows between the patient's knees Rationale: Placing small pillows between the patient's knees helps prevent tension in the spinal column and adduction of the hips. Crossing the patient's arms across the chest prevents injury to the arms. Placing the patient in the supine position on the side of the bed prepares the patient for turning onto the side. Fanfolding, or rolling the drawsheet alongside the patient, provides strong handles to grip the drawsheet.

While positioning a hemiplegic patient in the supported Fowler's position, the nurse positions the head of the patient against a small pillow with the chin slightly forward. What is the rationale behind this nursing action? A .Promote circulation B. Support lumbar vertebrae C. Prevent shoulder dislocation D. Prevent flexion contractures

D. prevent flexion contractures rationale: While positioning a hemiplegic patient who is unable to control head movement in the supported Fowler's position, the nurse should position the head on a small pillow with the chin slightly forward to prevent hyperextension of the neck. Using pillows to support the arms and hands of a patient who does not have voluntary control promotes circulation by preventing venous pooling. Positioning a small pillow at the lower back of a hemiplegic patient helps support the lumbar vertebrae and decreases flexion of the vertebrae. Use of pillows to support arms and hands may help prevent shoulder dislocation from the effect of a downward pull of unsupported arms.

The nurse manager is providing a verbal report to a group of team members. Which zone of personal space is indicated in the nurse's action? A. public zone B. intimate zone C. personal zone D. socio-consultative zone

D. socio-consultative zone Rationale: Communication in the socio-consultative zone may involve giving directions to visitors in the hallway or giving a verbal report to a group of nurses. In the public zone, the nurse speaks at a community forum and delivers a lecture to a class of students. In the intimate zone, the nurse performs physical assessment and changes a patient's surgical dressing. In the personal zone, the nurse sits at the patient's bedside.

The nurse is observing the nonverbal cues of a patient who has a quick and purposeful gait. What does the patient's gait indicate? A. the patient is attentive B the patient is nervous C. the patient is depressed D. the patient is confident

D. the patient is confident Rationale: Posture and gait convey important clues about a patient's health. A quick and purposeful gait indicates well-being and confidence. A patient who is attentive may lean forward. A nervous or depressed patient usually has a slumped posture and slow, shuffling gait.

Which positioning aid prevents external rotation of the hips when the patient is in the supine position? A. thin pillow B. thick pillow C. trapeze bar D trochanter roll

D. trochanter roll Rationale: A trochanter roll prevents external rotation of the hips when a patient is in the supine position. A thin pillow or thick pillow would not be helpful for preventing the external rotation of the hips, but may lead to increased flexion when the appropriate pillow size is not taken. The trapeze bar allows the patient to raise the upper extremities to raise the trunk off the bed, which helps in decreasing the shearing action from sliding across or up and down the bed.

While assessing a patient who has a pressure ulcer, the nurse finds black wound tissue. In which stage is this pressure ulcer? A. stage I B. stage II C. stage III D. unstageable

D. unstageable Rationale: Black tissue is characteristic of an eschar. Because the eschar obscures the depth of the wound, this ulcer is unstageable. Stage I ulcers manifest as localized nonblanchable redness over intact skin. Stage II ulcers are characterized by partial-thickness dermis loss. Stage III ulcers are characterized by full-thickness skin loss to the extent that subcutaneous fat may be visible.

The nurse provides a semi-solid diet to a patient, but the patient wants to have a solid diet. The nurse convinces the patient that having a solid diet would delay recovery and the patient ultimately agrees to the semi-solid diet. Which attitude does the nurse exhibit that promotes effective communication? A. Humility B. Curiosity C. Integrity D. Creativity

Integrity involves recognizing patients' opinions when they conflict with the nurse's opinions, reviewing positions, and finally determining how to communicate to reach mutually beneficial decisions. Humility involves the nurse asking for help if he or she is uncomfortable with an aspect of patient care. Curiosity involves the nurse being motivated to communicate and know more about a person. Creativity involves identifying innovative solutions.