41-50 Flashcards
The tissue surfaces of an incision that are brought together are described as:
Clean surgical incision
Primarily intention healing
There are several instruments for assessing patients who are at risk of developing a pressure injury. The Braden Scale is commonly used. What risk factors are assessed using the Braden Scale?
Sensory, moisture, activity, mobility, nutrition, friction, sheer.
The hemostasis phase of wound healing is characterized by:
For the body to stop bleeding
vascular spasm, platelet plug formation, coagulantion
The nurse observes that the client has a pressure injury on their right heel. There is full-thickness loss of the dermis. The nurse can see subcutaneous fat, but no muscle or
bone. Classify the stage of the pressure injury as:
Stage 3
The nurse uses a surgical aseptic technique when:
Procedures are technically complex and invasive
An effective question to assess orientation in a mental health assessment may include:
What day/month/time
What’s your name
Who am I
Place/person/location
You are caring for Mrs. X and her daughter Jane phones accusing staff of physically abusing her mother. Jane is very angry and upset and you recognize that the situation needs to be de-escalated. What is an appropriate approach with Jane?
Active listening
Paraphrasing
Remain calm
Empathetic aproach
Delirium is characterized by:
Confusion, disorientation, and restlessness
The nurse is performing a lymph node assessment on a client who has been complaining of a sore throat. In palpating for the occipital lymph nodes, the nurse must position the pads of their fingers in which position?
The base of the skull
Top of spine
Occipital bone
Which symptoms are commonly associated with enlarged head and neck lymph nodes?
Headache
Sore throat
Difficulty swallowing
Flu-like symptoms
