Name that Wound
Dead, necrotic tissue
What is eschar?
Recommended time frame to turn patients who are prone or who currently have a pressure ulcer.
What is every 2 hours?
Seven-year old boy, with a new baby sister, starts wetting the bed after baby sister comes home from the hospital.
What is Regression?
This diet contains only liquids or foods that turn to liquid at body temperature.
What is a full liquid diet?
The Newborn is usually fed _______; This method tends to decrease what?
How should Infant placed after feeding and burping?
On Demand; Decrease the problem of overfeeding and underfeeding.
Supine
Intact skin, reddened, doesn't blanch.
What is Stage I pressure ulcer?
When doing a physical assessment, these 4 areas should be especially assessed and document if skin breakdown occurs.
What is the areas of sacrum, buttocks, heels, & ischium?
In which level of anxiety does the patient experience extreme fright and horror? a) moderate b) mild c) severe d) panic
Which level of anxiety can a person still problem solve?
What is panic
What is mild anxiety
This diet is easily chewed and digested.
What is a soft diet?
Per My Food Plate - If I have 2 cups of milk per day... and IF I have 3 cups of milk per day...
What are the number of servings of milk for a child and what are number of servings for an older adult?
Crater-like ulcer, underlying subcutaneous tissue involved.
What is Stage III Pressure Ulcer?
Good tissue, pink in color and fragile.
What is granulated tissue?
A nurse is caring for a client who is experiencing moderate anxiety. Which of the following is an appropriate nursing intervention when trying to give necessary information to the client? a) Reassure the client that everything will be okay. b) Use a low pitched voice and speak slowly c) Ignore the client’s anxiety so that he/she will not be embarrassed. d) Demonstrate a calm manner while using simple and clear language.
What is d) Demonstrate a calm manner while using simple and clear language.
This diet contains tea, coffee, clear broths, strained clear juices, plain jello.
What is a clear liquid diet?
A client should avoid Vitamin K when taking warfarin (Coumadin) which is a blood thinner, why?
What is Vit. K can decrease the effectiveness of warfarin.
Partial thickness, (fluid filled) blistered skin.
What is Stage II Pressure Ulcer?
Removal of eschar or necrotic tissue.
What is debridement?
Freddy Mercury, of Queen, is getting to perform the concert of a life time, earlier that week he received some bad news that he doesn't have long to live. Although he is visibly upset, he puts the issue out of his mind until the concert is over, until he can give the whole issue it's full attention.
What is Suppression?
This diet can consist of cracked wheat bread, apple, prunes, and beans.
What is a fiber diet?
Administer this on an empty stomach, 1 hour before or 2 hours after meals, with a full glass of water. However, if it upsets my stomach I can take it with or after food, but not with coffee, tea or eggs. Do not lie down for 30 minutes after taking this.
What are nursing interventions for administering ferrous sulfate (Slow-Fe, Fesol)?
Deep ulceration & necrosis, possible bone involvement.
What is Stage IV Pressure Ulcer?
Determines patients susceptibility to skin breakdown.
What is the Braden Scale?
A client is angry about not being allowed to smoke and throws his bedpan at the nurse. What is the nurse's best response?
1. Tell the client that they're acting like child, so stop it.
2. Call the charge nurse and refuse to take care of the client until he is under control.
3. Tell the client that it is understandable that he is upset, but the no-smoking rule is not negotiable.
4. Apologize to him for the unit rules, but tell the rules must be followed.
Correct: 3. Tell the client that it is understandable that he is upset, but the no-smoking rule is not negotiable.
This diet that is rich in proteins, carbohydrates, lipids, vitamin A & C and minerals, such as iron, zinc, and copper.
What is a well balanced diet for wound healing?
What are some safety measures that the nurse can teach a family member when feeding their loved ones to prevent aspiration? p. 1139
What are: 1. Chin tuck method if having dysphagia 2. Foods that are prepared and prescribed proper consistency 3. At mealtime - keep it positive social occasion with positive interaction; keep the environment neat and clean and pleasant 4. Focus on foods that the client likes.