A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Motor impairment

Pain

The client's culture

Hearing loss

Answer and Explanation

The Correct Answer is B

A. An abrasion is a superficial wound caused by scraping or rubbing and does not involve the full thickness of the skin.

B. A full-thickness wound with jagged edges and visible muscle tissue is a laceration. Lacerations are typically caused by trauma and result in irregular edges and deeper tissue damage.

C. A puncture wound is caused by a sharp object penetrating the skin, often with a small opening.

D. A contusion is a bruise caused by blunt force trauma that results in damage to underlying tissues but does not involve a break in the skin.

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Correct Answer is D

Explanation

A. Quaternary prevention focuses on preventing over-medicalization or unnecessary interventions in health care.

B. Tertiary prevention aims to reduce the impact of an already established disease, such as rehabilitation.

C. Secondary prevention focuses on early detection of disease to prevent progression, such as through screenings.

D. Primary prevention aims to prevent the onset of disease or injury before it occurs. Immunizations and water fluoridation are both measures that help prevent disease in the general population before it starts.

A. Elevate the head of the bed no more than 45°. B. Use a transfer device to lift the client up in bed. C. Apply cornstarch to keep sensitive skin areas dry. D. Massage the skin over the client's bony prominences.

Correct Answer is B

Explanation

A. Elevating the head of the bed no more than 30° (not 45°) is recommended to avoid pressure on the sacrum and reduce the risk of developing pressure ulcers.

B. Using a transfer device helps to reduce friction and shear, which can prevent further damage to the skin, especially in clients at risk for pressure ulcers.

C. Cornstarch should not be applied to sensitive skin areas due to the risk of skin irritation and fungal growth.

D. Massaging bony prominences can cause tissue damage and should be avoided, as it increases the risk of skin breakdown.

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A nurse is completing discharge teaching with a client. Of the following barriers to learning the nurse identifies with this client, which should the nurse interpret as a need to postpone the session?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Preventive measures such as immunizations and water fluoridation are examples of which type of prevention?

Correct Answer is D

Explanation

A nurse is planning care for an older adult client who is at risk for developing pressure ulcers. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is B

Explanation

A nurse is reviewing the laboratory results of a client who has a pressure ulcer. The nurse should identify an elevation in which of the following laboratory values as an indication that the client has developed an infection?

A nurse is preparing to teach a client who has a low literacy level. Which of the following methods should the nurse plan to include?

A nurse is admitting a client who has tuberculosis and a productive cough. Which of the following types of isolation precautions should the nurse initiate for the client?

A nurse is auscultating the breath sounds of a client who has asthma. When the client exhales, the nurse hears continuous high-pitched squeaking sounds. The nurse should document this as which of the following adventitious breath sounds?

A nurse is providing nail care for a client. Which of the following actions should the nurse take?

Which division of the United States Department of Health and Human Services is primarily responsible for the administrative provisions of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)?

A nurse is assessing for cyanosis in a client who has dark skin. Which of the following sites should the nurse examine to identify cyanosis in this client?

A nurse is preparing a presentation at a senior center about age-related musculoskeletal changes. Which of the following changes should the nurse plan to include?