Miscellaneous
This pressure injury stage is characterized by nonblanchable erythema with intact skin.
What is Stage 1?
These two findings are commonly associated with rheumatoid arthritis rather than osteoarthritis.
What is swan neck deformities and morning stiffness?
This client should be seen first
A. Client with osteoporosis requesting pain medication
B. Client with RA reporting fatigue
C. Client with a cast reporting numbness and absent pedal pulse
D. Client with osteoarthritis requesting assistance to ambulate
What is the client with a cast reporting numbness and absent pedal pulse?
An older adult who is incontinent and immobile is at risk for this...
What is a pressure ulcer?
This client should be seen first
A. Client with OA requesting a warm compress
B. Client with Stage 2 pressure injury requesting repositioning
C. Client with fracture reporting severe pain unrelieved by medication and increasing numbness
D. Client with RA asking about exercise
What is C, Client with fracture reporting severe pain unrelieved by medication and increasing numbness?
This assessment tool evaluates a client's risk for pressure injury development.
What is a Braden Scale?
This type of wound healing occurs when wound edges are approximated.
What is Primary Intention?
This pressure injury stage involves full-thickness skin loss with visible adipose tissue.
What is stage 3?
This nursing action should be avoided when caring for a Stage 1 pressure injury.
What is massaging the area?
This teaching indicates understanding of osteoporosis prevention.
A. "I should avoid exercise."
B. "I will increase my weight-bearing activities."
C. "I will stay in bed when possible."
D. "I should limit calcium intake."
What is B, "I will increase my weight-bearing activities."?
This nutrient is most important for tissue repair and wound healing.
What is protein?
This stage of wound healing occurs immediately after injury and involves clot formation
What is hemostasis?
This nursing diagnosis is most appropriate for a client confined to bed with limited movement.
What is impaired skin integrity?
This complication of immobility affects the respiratory system.
What is atelectasis?
This wound healing phase is characterized by granulation tissue formation.
What is Proliferative?
This intervention should be prioritized by the nurse to prevent pressure injuries.
What is frequent repositioning or turning?
This complication of immobility places the client at risk for pulmonary embolism.
What is DVT?
This intervention helps prevent contractures.
What is ROM exercises?
This assessment finding is most concerning after a fracture.
A. Mild edema
B. Pain rated 4/10
C. Inability to feel toes
D. Bruising around the injury
What is C, the inability to feel toes?
This is the nurse's highest priority intervention for an immobile client with a Braden score of 10 and non-blanchable sacral redness.
What is Implement pressure-relief measures and reposition immediately
The nurse is teaching a client newly diagnosed with osteoarthritis. This statement best describes the disease process.
What is the degeneration of articular cartilage?
These findings are included in the "6 P's" of neurovascular assessment
What is Pain, Pallor, Pulselessness, Paresthesia, Paralysis, and Poikilothermia?
This finding suggests wound infection.
What is purulent drainage?
**The drainage may have a foul odor.
This intervention promotes both mobility and pressure injury prevention.
What is early ambulation?
A nurse is assessing a client 8 hours after surgical repair of a fractured femur. Which findings should the nurse recognize as signs of neurovascular compromise? Select all that apply.
A. Capillary refill less than 2 seconds
B. Severe pain unrelieved by analgesics
C. Numbness and tingling of the foot
D. Pale, cool extremity
E. Strong pedal pulse
F. Inability to move the toes
What is B, C, D, & F?