Final Exam: NUR 2356/ NUR2356 (NEW
2023/ 2024) Multidimensional Care I/ MDC 1
Exam Review | Modules 8-10 Covered| (100%
Correct) Complete Guide with
... [Show More] Questions and Verified Answers - Rasmussen
QUESTION
A 65-year-old client with hemiparesis and incontinence is at great risk for
Answer:
•pressure injury development
QUESTION
•Nursing interventions to decrease the risk of pressure injury for a client who is bedridden and
appears frail and malnourished include:
Answer:
•Cleansing the skin routinely after soiling occurs
•Apply moisturizer to dry areas of the skin
•Using a Hoyer lift for all transfers
•Do not massage the client's reddened shoulders and heals
•Reposition every 2 hours
QUESTION
•Nutrition plays a key role in healing from a pressure injury what should you do
Answer:
•Encourage protein intake at each meal
•Serve protein shakes between meals
•E.g., client asks why they are getting protein supplements
•Nurse's best response to explain that protein has amino acids that promote wound healing
QUESTION
The orthopedic nurse caring for a group of hospitalized clients understands that an older adult
who has a hip fracture and is immobile is at a high risk for
Answer:
•skin breakdown
QUESTION
Braden scale assessment includes
Answer:
•sensory perception, friction and sheer, and nutrition
QUESTION
Shearing or fiction force can result in
Answer:
an injury to client's heel when moving a client up in bed
QUESTION
•Nurse assessing an area of skin over a bony prominence notes blanching, warmth, and redness
what does that tell you
Answer:
•Nurse would be most concerned if the skin was non-blanching
•Non-blanching is would be concerning as the area stays red which means that there is little or no
blood flow going to that area
QUESTION
An area of erythema on the skin is
Answer:
•being assessed by the nurse
•The nurse presses down on the area, and the area becomes white
•Blanching is the term used to document this finding
QUESTION
Stage 2 Pressure Injury
Answer:
•partial-thickness loss with exposed dermis
• - E.g., Nurse assesses a shallow, open, reddened ulcer with no slough on the left heel
QUESTION
Stage 4 Pressure Injury
Answer:
•full-thickness loss of skin and tissue
•Full-thickness skin loss with exposed or palpable fascia, muscle, tendon, ligament, cartilage, or
bone
•E.g., nurse observes bone and tendon at the base of a client's pressure injury
QUESTION
Client sitting in a high-fowler's position is at risk for
Answer:
•a shearing injury
QUESTION [Show Less]