ch 10 hit II

The initial sign of pressure ulcer is erythema, which normally resolves in less than

1 hour

walker is at the right height when the client's elbows are in which position?

25-degree flexion

normal albumin range

3.4 to 5.4 g/dL. If you have a lower albumin level, you may have malnutrition

When assessing a client's risk for pressure ulcer development, which finding would alert the nurse to an increased risk? Select all that apply. Constipation Edema Sensory overload Anemia Diaphoresis

Anemia, Diaphoresis, edema

functional urinary incontinence

Client does not reach the toilet before experiencing voiding.

ligament

Connects bone to bone

Tendon

Connects muscle to bone

Which explanation demonstrates safe walker use?

Moving the walker, stepping with the affected leg, then stepping with the unaffected leg

which process transforms osteoblasts into mature bone cells?

Ossification and calcification

How can the nurse prevent continuous moisture on the skin of a patient who is at risk for developing skin breakdown?

Practice meticulous hygiene measures.

range-of-motion exercise and moves the patient's hand sideways so that the little finger moves toward the forearm

Ulnar deviation

Which nursing intervention will help to prevent contractures?

applying splints

Reflex (neurogenic) incontinence

associated with a spinal cord injury that interrupts cerebral control resulting in no sensory awareness of the need to void

Through which activity does a client learn to consciously contract excretory sphincters and control voiding cues?

biofeedback

cause of erythema

hyperemia

Barthel Index of ADL

measurement tool to determine a patient's level of independence in activities of daily living, such as continence, toileting, transfers, and ambulation

Which therapeutic exercise is done by the nurse without assistance from the client?

passive

air-fluidized surface

protects the skin from moisture

The nurse assesses soft subcutaneous nodules along the line of the tendons in a patient's hand and wrist. What does this finding indicate to the nurse?

rheumatoid arthritis

Braden Scale

sensory perception, moisture, activity, mobility, nutrition, friction and shear

Half of all spinal cord injuries are related to

substance abuse