Nursing Fundamentals Quiz 5

A woman with sensorineural Hearing Loss with comes in for her annual check-up. What are expected finding for her hearing condition?

Tinnitus (ringing, roaring, humming in ears) Dizziness Hears poorly in a noisy environment Speaks loudly No otoscopic finding

What is sensory perception

the ability to receive and interpret sensory impressions.

What is an otoscopy?

visual examination of the ear canal with an otoscope

How do you interpret sensory impressions?

•sight (visual), •hearing (auditory), •touch (tactile), •smell (olfactory), •taste (gustatory), and •movement or position (kinesthetic).

Eye protection is an example of what type of prevention? (Primary, Secondary or Tertiary?)

Primary

What type of prevention is this: Immunization programs Child car seat education Nutrition, fitness activities Health education in schools

Primary

A patient returns to their room following a surgical procedure where they where staples and sutures were used to seal a deep laceration in the upper thigh. This is an example of what kind of wound healing? A. Primary Intention B. Secondary Intention C. Tertiary Intention

Primary intention: Little or no tissue loss Edges approximated, as with a surgical incision Heals rapidly Low risk of infection No or minimal scarring Example: Closed surgical incision with staples, sutures, or liquid glue to seal laceration

Match the Stages of the healing process to their characteristics Primary Intention Secondary Intention Tertiary Intention A. the wound is left open until it becomes filled with scar tissue. Wound edges are widely separated, and approximated (pressure injury, open burn areas) Longer healing time Increase in risk of infection Scarring Heals by granulation. B. Widely separated. Deep Spontaneous opening of a previously closed wound Closure of wounds occurs when they are free of infection and edema. Risk of Infection Long healing time Closed Later C. Little or no tissue loss the skin edges are approximated, or closed, Heals rapidly. Low risk of infection No or minimal scarring.

Primary: C Secondary: A Tertiary: B

A nurse is teaching a newly licensed nurse about interventions for clients who have sensory deprivation or overload. Which of the following interventions should be implemented for patients who have sensory overload? Select all that apply. A. Encourage the client's family to visit with the client. B. Communicate frequently with the client. C. Increase the ringer volume on the client's phone. D. Provide a private room E. Dim lighting in the room F. Limit visitors

Provide a private room Dim lighting in the room Limit visitors

Getting an eye exam every 2 years is an example of what type or prevention?

Secondary

What type of prevention is this: Communicable disease screening, case finding Early detection, and treatment of diabetes mellitus Exercise programs for older adults who are frail

Secondary

What type of prevention is this: Begins after an injury or illness Prevention of pressure ulcers after spinal cord injury Promoting independence after traumatic brain injury Referrals to support groups Rehabilitation center

Tertiary

Evisceration

The displacement of organs outside of the body.

serous drainage

The portion of the blood (serum) that is watery and clear or slightly yellow in appearance (fluid in blisters).

purulent drainage

The result of infection. It is thick and contains white blood cells, tissue debris, and bacteria. It may have a foul odor, and its color (yellow, tan, green, brown).

What 2 things should you NOT do for patients ​​​​who have hearing loss

cover mouth when speaking & shout

isometric exercise

exercise in which muscle tension occurs without a change in muscle length

What are expected findings with visual deficits:

headaches eye strain Blurred vision Diplopia: double vision Poor hand-eye coordination

What is sensorineural hearing loss?

hearing loss caused by damage to the inner ear, auditory nerve, or the hearing center of the brain.

What is conductive hearing loss?

hearing loss that is due to diminished sound reaching the middle and inner ear.

What is the major sleep center in the body?

hypothalamus

What is audiometry?

is a hearing test that can identify whether hearing loss is sensorineural and/or conductive

Visual Acquity

is the degree in which image i perceived

sensory overload

is the excessive, sustained, and unmanageable multisensory stimulation

What does a tympanogram do?

it measures the mobility of the tympanic membrane and middle ear structures

What is diabetic retinopathy?

leakage and blockage of retinal blood vessels; can lead to retinal hypoxia, retinal hemorrhages, blindness

Purosanguineous

mixed drainage of pus and blood (newly infected wound).

Dehiscence

partial or total separation of wound layers

body alignment/posture

positioning of the joints, tendons, ligaments, and muscles while standing, sitting, and lying

sensory deprivation

reduced sensory input from the internal or external environment.

What are ways you can prevent pressure injuries?

relieve the pressure and provide optimal nutrition and hydration

*Which skin-care measures are used to manage a patient who is experiencing fecal and/or urinary incontinence? (select all that apply)* 1) Frequent position changes 2) Keeping the buttocks exposed to air at all times 3) Using a large absorbent diaper, changing when saturated 4) Using an incontinence cleaner 5) Frequent cleaning, applying an ointment, and covering the areas with a thick absorbent towel 6) Applying a moisture barrier ointment

*Answer: 1, 4, 6* Rationale: Skin that is in contact with stool and urine can become moist and soft, allowing it to become damaged. The stool contains bacteria and in some cases enzymes that can harm the skin if in contact for a prolonged period of time. The use of an incontinence cleaner provides a gentle removal of stool and urine, and the use of the moisture-barrier ointment provides a protective layer between the skin and the next incontinence episode. However, skin-care and moisture barriers must also be used with frequent position changes to help reduce the risk for pressure ulcers.

*Match the pressure ulcer categories/stages with the correct definition:* 1) Category/stage I 2) Category/stage II 3)Category/stage III 4)Category/stage IV a) Nonblanchable redness of intact skin. Discoloration, warmth, edema, or pain may also be present. b) Full-thickness skin loss; subcutaneous fat may be visible. May include undermining. c) Full thickness tissue loss; muscle and bone visible. May include undermining. d) Partial-thickness skin loss or intact blister with serosanguinous fluid.

*Answer: 1a, 2d, 3b, 4c* Rationale: Category/stage I pressure ulcer does not have a break in the skin but has a redness that does not blanch. Category/stage II ulcer has a shallow open ulcer (partial-thickness wound). It may also have an intact fluid-filled blister. Category/ stage III is full-thickness damage without visible fat; however, bone, tendon, and muscle are not exposed. Category/stage IV has full-thickness damage with visible bone, tendon, or muscle exposed.

What does the Braden Scale evaluate?* 1) Skin integrity at bony prominences, including any wounds 2) Risk factors that place the patient at risk for skin breakdown 3) The amount of repositioning that the patient can tolerate 4) The factors that place the patient at risk for poor healing

*Answer: 2* Rationale: The Braden Scale measures factors in six subscales that can predict the risk of pressure ulcer development. It does not assess skin or wounds.

*On assessing your patient's sacral pressure ulcer, you note that the tissue over the sacrum is dark, hard, and adherent to the wound edge. What is the correct category/stage for this patient's pressure ulcer?* 1) Category/stage II 2) Category/stage IV 3) Unstageable 4) Suspected deep-tissue damage

*Answer: 3* Rationale: To determine the category/stage of a pressure ulcer you examine the depth of the tissue involvement. Since the pressure ulcer assessed was covered with necrotic tissue, the depth could not be determined. Thus this pressure ulcer cannot be staged.

Which of the following describes a hydrocolloid dressing?* 1) A seaweed derivative that is highly absorptive 2) Premoistened gauze placed over a granulating wound 3) A debriding enzyme that is used to remove neurotic tissue 4) A dressing that forms a gel that interacts with the wound surface

*Answer: 4* Rationale: A hydrocolloid dressing is made of materials that are adhesive and can form a gel over the open area of the wound. Since moisture enhances wound healing, the gel that forms places the wound in the proper environment for healing.

*When repositioning an immobile patient, the nurse notices redness over the hip bone. What is indicated when a reddened area blanches on fingertip touch?* 1) A local skin infection requiring antibiotics 2) Sensitive skin that requires special bed linen 3) A stage III pressure ulcer needing the appropriate dressing 4) Blanching hyperemia, indicating the attempt by the body to overcome the ischemic episode

*Answer: 4* Rationale: When repositioning an immobile patient, it is important to assess all bony prominences for the presence of redness, which can be the first sign of impaired skin integrity. Pressing over the area compresses the blood vessels in the area; and, if the integrity of the vessels is good, the area turns lighter in color and then returns to the red color. However, if the area does not blanch when pressure is applied, tissue damage is likely.

*Match the stages of healing with the correct outcome.correct definition:* 1) Inflammatory 2) Proliferative 3) Maturation/Remodeling A. Bleeding is controlled by vasoconstriction, clot formation, and fibrin accumulation. Oxygen, white blood cells, and nutrients are sent to the injured area via the blood supply. Phagocytosis begins. B. starts around the 21st day) involves the strengthening of the collagen scar and the restoration of a more normal appearance C. 3-24 days after injury) Lost tissue is replaced with connective tissue or collagen. Resurfacing of new epithelial cells.

1) Inflammatory: A 2) Proliferative: C 3) Mature/Remodeling: B

After surgery the patient with a closed abdominal wound reports a sudden "pop" after coughing. When the nurse examines the surgical wound site, the sutures are open, and small bowel sections are observed at the bottom of the now-opened wound. Which are the priority nursing interventions? (Select all that apply.) 1. Notify the health care provider. 2. Allow the area to be exposed to air until all drainage has stopped. 3. Place several cold packs over the area, protecting the skin around the wound. 4. Cover the area with sterile, saline-soaked towels immediately. 5. Cover the area with sterile gauze and apply an abdominal binder. 6. Stay with the Patient 7. attempt to reinsert the organs.

1. Notify the health care provider. 4. Cover the area with sterile, saline-soaked towels immediately. 6. Stay with the Patient

Which of the following are measures to reduce tissue damage from shear? (skin friction) 1. Use a transfer device (e.g., transfer board). 2. Have head of bed elevated when transferring patient. 3. Have head of bed flat when repositioning patient. 4. Raise head of bed 60 degrees when patient is positioned supine. 5. Raise head of bed 30 degrees when patient is positioned supine.

1. Use a transfer device (e.g., transfer board). 3. Have head of bed flat when repositioning patient. 5. Raise head of bed 30 degrees when patient is positioned supine.

What is a cataract?

A condition in which the lens of the eye becomes opaque or cloudy.

Narcolepsy

A sleep disorder characterized by uncontrollable sleep attacks.

A nurse is teaching a newly licensed nurse about interventions for clients who have sensory deprivation or overload. Which of the following interventions should be implemented for patients who have sensory deprivation Select all that apply. A. Encourage the client's family to visit with the client. B. Communicate frequently with the client. C. Increase the ringer volume on the client's phone. D. Provide a private room E. Dim lighting in the room F. Limit visitors

A. Encourage the client's family to visit with the client. B. Communicate frequently with the client. C. Increase the ringer volume on the client's phone.

A nurse in a health clinic is caring for a 21-year-old client who tells the nurse that their last physical exam was in high school. Which of the following health screenings should the nurse expect the provider to perform for this client? A. Testicular examination B. Blood glucose C. Fecal occult blood D. Prostate-specific antigen

A. Testicular examination The nurse should identify that starting at puberty, the client should have examinations for testicular cancer, along with blood pressure and body mass index and cholesterol measurements. Testicular cancer is most common in males 15 to 34 years of age.

A client who had abdominal surgery 24 hr ago suddenly reports a pulling sensation and pain in their surgical incision. The nurse checks the surgical wound and finds it separated with viscera protruding. Which of the following actions should the nurse take? (Select all that apply) Hint- only 2 Use sterile gauze to apply gentle pressure to the exposed tissues. Apply an abdominal binder snugly around the abdomen. Offer the client a warm beverage (herbal tea). Position the client supine with the hips and knees bent. Cover the area with saline-soaked sterile dressings.

A. Cover the area with saline-soaked sterile dressings. When taking action, the nurse should cover the wound with a sterile dressing soaked with sterile normal saline solution to keep the exposed organs and tissues moist until the surgeon can assess and intervene. D. Position the client supine with the hips and knees bent. The nurse should place the client supine with the hips and knees bent. This position minimizes pressure on the abdominal area.

A nurse in a clinic is planning health promotion and disease prevention strategies for a client who has multiple risk factors for cardiovascular disease. Which of the following interventions should the nurse include? Select all that apply. A. Help the client see the benefits of their actions. B. Identify the client's support systems. C. Suggest and recommend community resources. D. Devise and set goals for the client. E. Teach stress management strategies.

A. Help the client see the benefits of their actions. B. Identify the client's support systems. C. Suggest and recommend community resources. E. Teach stress management strategies. FALSE- Devise and set goals for the client. The rationale for being false. The nurse and the client should work together to devise and set mutually agreeable goals that are realistic and achievable.

A nurse is caring for a client who is at risk for developing pressure injury. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin? A. Keep the head of the bed elevated 30°. B. Massage the client's bony prominences frequently. C. Apply cornstarch liberally to the skin after bathing. D. Have the client sit on a gel cushion when in a chair. E. Reposition the client every 3 hr while in bed.

A. Keep the head of the bed elevated 30°. When generating solutions, the nurse should identify that slightly elevating the head of the client's bed helps to reduce shearing forces that could tear sensitive skin on the sacrum, buttocks, and heels. D. Have the client sit on a gel cushion when in a chair. The nurse should also have the client sit on a gel, air, or foam cushion to redistribute weight away from ischial areas.

A nurse is caring for a client who had a stroke and has aphasia. Which of the following actions should the nurse take to promote communication? Select all that apply. A. Make sure one person speaks to the client at a time. B. Let the client know if they are not understood. C. Allow time for the client to respond. D. Use long sentences when talking to the client. E. Speak loudly to the client.

A. Make sure one person speaks to the client at a time. B. Let the client know if they are not understood. C. Allow time for the client to respond. When taking actions, the nurse should allow one person to speak to the client at a time, let the client know when they do not understand them, and allow plenty of time for the client to respond. These actions will facilitate communication in the client who has aphasia.

Hypersomnolence Disorder

Characterized by excessive sleepiness. Occurs at least three times a week for at least three months.

The nurse is educating the client about ways to improve sleep. Which of the following recommendations should the nurse include? Select all that apply. A. Practice muscle relaxation techniques. B. Exercise each morning C. Take two 30-minute naps each day. D. Avoid heavy meals before bedtime E.Limit fluid intake at least 1 hr before bedtime

A. Practice muscle relaxation techniques. B. Exercise each morning D. Avoid heavy meals before bedtime

A nurse is preparing a presentation at a local community center about sleep hygiene. Which of the following characteristics are considered to be rapid eye movement (REM)? (Select all that apply) A. brain tissue restoration B. loss of muscle tone C. 75% of sleeping time D. Dreaming E. Muscle Relaxation F. More easily awoken G. Usually occurs 90 minutes after falling asleep H. Light Sleep

A. brain tissue restoration B. loss of muscle tone D. Dreaming G. Usually occurs 90 minutes after falling asleep

A nurse at a health department is planning strategies related to heart disease. Which of the following activities should the nurse include as part of primary prevention? A. Providing cholesterol screening B. Teaching about a healthy diet C. Providing information about antihypertensive medications D. Developing a list of cardiac rehabilitation programs

B. Teaching about a healthy diet Rationale: Primary prevention encompasses strategies that help prevent illness or injury. This level of prevention includes health information about nutrition, exercise, stress management, and protection from injuries and illness.

A nurse at a provider's office is talking about routine screenings with a 45-year-old female client who has no specific family history of cancer or diabetes mellitus. Which of the following client statements indicates that the client understands how to proceed? A. "I'll need a colonoscopy in 5 years." B. "For now, I should continue to have a clinical breast exam each year." C. "Because the doctor just did a Pap smear, I'll come back next year for D. "I had my blood glucose test last year, so I won't need it again for 4 years."

B. "For now, I should continue to have a clinical breast exam each year." The female client who is between the ages of 40 and 49 should have a clinical breast exam annually, and they should consult with their provider about the frequency of mammograms.

A nurse is instructing a client who has narcolepsy. Which of the following client statements indicates an understanding of the instructions? A. "I will add plenty of carbohydrates to my meals." B. "I will take a short nap when I feel sleepy." C. "I will increase the heat in my office, so I stay warm." D. "I will limit alcohol intake to one drink per day."

B. "I will take a short nap when I feel sleepy."

You are educating a new nurse on preventative measures for hearing loss. What would you include in this teaching? (Select all that apply) A. Clean your ears with cotton-tipped swabs B. Keep Volume of earphones at a comfortable level C. Wear protective gear when exposed to high-intensity noises. D. Rubbed your ears with pressure when irritated E. Use a commercial ceruminolytic (ear drops that soften cerumen) for impactions.

B. Keep Volume of earphones at a comfortable level C. Wear protective gear when exposed to high-intensity noises. E. Use a commercial ceruminolytic (ear drops that soften cerumen) for impactions.

A nurse is caring for a 45-year-old client who is 2 days postoperative following an appendectomy and has type I diabetes mellitus. Their Hgb is 12 g/dL and BMI is 17.1. The incision is approximated and free of redness, with scant serous drainage on the dressing. The nurse should recognize that the client has which of the following risk factors for impaired wound healing? Select all that apply (3) A. Age B. Low Hemoglobin C. Malnutrition D. Chronic Illness E. Gender

B. Low hemoglobin: Hemoglobin is essential for oxygen delivery to healing tissues, and this client's hemoglobin level is low. C. Malnutrition: A BMI of 17.1 indicates that the client is underweight and, therefore, malnourished. Deficiencies in essential nutrients delay wound healing. D. Chronic illness: When analyzing cues, the nurse should identify that diabetes mellitus is a chronic illness that places additional stress on the body's healing mechanisms.

A 58-year-old man comes into the clinic. You notice that he hears better in a noisy environment, speaks softly, has an obstruction in the external canal (packed cerumen), and has tympanic membrane scarring. What do these expected findings correlate with?

Conductive Hearing Loss

A nurse is reviewing instructions with a patient who has a new prescription for hearing aids. Which of the following client statements indicates an understanding of the instructions? A. "I will clean the ear molds of my hearing aids with rubbing alcohol each day." B. "I will use hairspray to keep my hair away from my hearing aids." C. "I will take the batteries out of my hearing aids when I take them off at night." D. "I will soak my hearing aids in warm water once each week."

C. "I will take the batteries out of my hearing aids when I take them off at night." To conserve battery power, the client should turn off the hearing aids and remove the batteries when not in use.

A nurse is preparing a presentation at a local community center about sleep hygiene. Which of the following characteristics are considered to be non rapid eye movement (NREM)? Select All that apply. A. brain tissue restoration B. loss of muscle tone C. 75% of sleeping time D. Dreaming E. Muscle Relaxation F. More easily awoken G. Usually occurs 90 minutes after falling asleep H. Light Sleep

C. 75% of sleeping time E. Muscle Relaxation F. More easily awoken H. Light Sleep

serosanguineous drainage

Contains both serum and blood. It is watery and looks pale and pink due to a mixture of red and clear fluid.

sanguineous drainage

Contains serum and red blood cells. It is thick and appears reddish.

Resistive isometric exercises

Contraction of muscles while pushing against a stationary object or resisting the movement of the object (push-ups)

What are the common eye disorder?

Presbyopia Cataracts Glaucoma Diabetic neuropathy Macular degeneration

insomnia

Difficulty in falling asleep or staying asleep

Isotonic exercises

Exercises in which a muscle lengthens and shortens through its full range of movement while lowering and raising a resistance.

Match the following age groups with the amount of sleep required. Infants & Toddlers Adolescents Adults Options for Answers: A. 9 to 10 hr/day B. 9 to 15 hr/day C. 7 to 8 hr/day

Infants & Toddlers: Need 9 to 15 hr/day Adolescents: Need 9 to 10 hr/day Adults: Need 7 to 8 hr/day

At what stage does drainage occur during wound healing?

Inflammatory and Proliferative Stage

A nurse is assessing a client who reports insomnia. Which of the following findings can contribute to the client's insomnia? Select all that apply. Irregular schedule Warm Bath Stress and anxiety Morning Walk Meditation Alcohol

Irregular schedule Stress and anxiety Alcohol

A charge nurse is providing education for a recent RN graduate. They are discussing client education on sleep. The new RN demonstrates proper understanding by stating all of the following EXCEPT.. Select all that apply. A. It is best to complete exercise 3 hours before bedtime B. Limit fluids 6-7 hours before bedtime C. Limit alcohol, caffeine, and nicotine at least 4 hr before bedtime D. Being on your phone and watching tv can help you fall asleep sooner. E. Arrange the sleep environment for comfort

Limit fluids 6-7 hours before bedtime (false) you should limit fluids 2 to 4 hr before bedtime. Being on your phone and watching TV can help you fall asleep sooner (FALSE) Bright lights are a stimulant that can make it difficult to fall asleep.

A nurse in an acute care facility is caring for a client who is having difficulty sleeping at night. What actions should the nurse take to promote sleep?

Limit wakening the patient at night Promote a quite environment Help patients establish and follow a bedtime routine Back rubs can lead to increased relaxation

What 2 body systems coordinate movement?

Musculoskeletal system & Nervous System

Match the following age groups with their physical development. Newborns Infants Adolescents Middle Age Older Adults Description: A. have a large amount of cartilage which is highly flexible but unable to support weight. B. are going through hormonal changes and bone resorption that result in progressive loss of total bone mass. C. have a full musculoskeletal function. D. musculoskeletal development focuses on support of weight for standing and walking. E. growth is often sporadic and uneven. Hips widen, and fat deposits in the upper arms, thighs, and buttocks.

Newborns- A. have a large amount of cartilage which is highly flexible but unable to support weight. Infants: D. musculoskeletal development focuses on support of weight for standing and walking. Adolescents: E. growth is often sporadic and uneven. Hips widen, and fat deposits in the upper arms, thighs, and buttocks. Middle Age: C. have a full musculoskeletal function. Older Adults: B. are going through hormonal changes and bone resorption that result in progressive loss of total bone mass.

A nurse is teaching a newly licensed nurse about assessing clients who have hearing loss. Which of the following findings correspond with conductive hearing loss? Select all that apply. A. Tinnitus (ringing, roaring, humming in ears) B. Speaks loudly C. Speaks softly D. Weber test result that indicates the tuning fork sound is heard better in the unaffected ear (lateralized to unaffected ear) E. Obstruction in external canal (packed cerumen) F. Hears better in a noisy environment G. Weber test result that indicates the tuning fork sound is heard better in the affected ear (lateralized to affected ear)

Speaks softly Weber test result that indicates the tuning fork sound is heard better in the affected ear (lateralized to affected ear) Obstruction in external canal (packed cerumen) Hears better in a noisy environment

Match the following TREATMENT for Deep Tissue Injuries Stage 1 Stage 2 Stage 3 Stage 4 A. Relieve pressure. Encourage frequent turning and repositioning. Use pressure-relieving devices (an air-fluidized bed). Implement pressure-reduction surfaces (air mattress, foam mattress). Keep the client dry, clean, well-nourished, and hydrated. B. Clean and/or debride with the following. •Prescribed dressing •Surgical intervention •Proteolytic enzymes •Perform nonadherent dressing changes every 12 hr. •Treatment can include skin grafts or specialized therapy (hyperbaric oxygen). •Provide nutritional supplements. •Administer analgesics. •Administer antimicrobials (topical and/or systemic). C. Clean and/or debride with the following. Prescribed dressing Surgical intervention Proteolytic enzymes Provide nutritional supplements. Administer analgesics. Administer antimicrobials (topical and/or systemic). D. Maintain a moist healing environment (saline or occlusive dressing). Apply hydrocolloid dressing. Promote natural healing while preventing the formation of scar tissue. Provide nutritional supplements. Administer analgesics.

Stage 1 A. Relieve pressure. Encourage frequent turning and repositioning. Use pressure-relieving devices (an air-fluidized bed). Implement pressure-reduction surfaces (air mattress, foam mattress). Keep the client dry, clean, well-nourished, and hydrated. Stage 2: D. Maintain a moist healing environment (saline or occlusive dressing). Apply hydrocolloid dressing. Promote natural healing while preventing the formation of scar tissue. Provide nutritional supplements. Administer analgesics. Stage 3: C. Clean and/or debride with the following. Prescribed dressing Surgical intervention Proteolytic enzymes Provide nutritional supplements. Administer analgesics. Administer antimicrobials (topical and/or systemic). Stage 4: B. Clean and/or debride with the following. •Prescribed dressing •Surgical intervention •Proteolytic enzymes •Perform nonadherent dressing changes every 12 hr. •Treatment can include skin grafts or specialized therapy (hyperbaric oxygen). •Provide nutritional supplements. •Administer analgesics. •Administer antimicrobials (topical and/or systemic).

A nurse is reviewing the wound healing process with a group of newly licensed nurses. The nurse should include in the information which of the following alterations for wound healing by secondary intention? (select all that apply) (hint only 2) stage 3 pressure injury Casted bone fracture Open burn area Sutured surgical incision Laceration sealed with adhesive

Stage 3 pressure injury: When taking action, the nurse should include that open pressure injuries heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges. Open burn area: Open burn areas heal by secondary intention, which is the process for wounds that have tissue loss and widely separated edges.

A nurse is teaching a newly licensed nurse about assessing clients who have hearing loss. Which of the following findings correspond with sensorineural hearing loss? Select all that apply. A. Tinnitus (ringing, roaring, humming in ears) B. Speaks loudly C. Speaks softly D. Weber test result that indicates the tuning fork sound is heard better in the unaffected ear (lateralized to unaffected ear) E. Obstruction in external canal (packed cerumen) F. Hears better in a noisy environment G. Weber test result that indicates the tuning fork sound is heard better in the affected ear (lateralized to affected ear)

Tinnitus (ringing, roaring, humming in ears) Speaks loudly Weber test result that indicates the tuning fork sound is heard better in the unaffected ear (lateralized to unaffected ear)

What causes pressure injuries?

Unrelieved pressure on the skin, usually over a bony prominence

A nurse is teaching a newly licensed nurse about contributing factors for sensory alterations. What contributing factors should the nurse include in the teaching?

Vision Loss Taste Deficit Conductive hearing loss sensorineural hearing loss Neurologic Deficits Stroke

What is sensory deficit?

a change in the normal reception and or perception.

sleep apnea

a disorder in which the person stops breathing for brief periods while asleep.

What are (3) Manifestations of sensory deprivation?

cognitive: •decreased ability to learn, disorientation), Affective: •(restlessness, anxiousness), or Perceptual: •(decreased coordination, decreased color perception).

What is glaucoma?

condition of increased intraocular pressure, which can lead to blindness