The long-term care facility nurse making a list of residents whose foot care must be referred to the podiatrist would include the ________________________. (Select all that apply.)
a. 90-year-old poststroke patient with right hemiparesis.
b. 85-year-old diabetic patient who is 100 pounds overweight.
c. 80-year-old resident with phlebitis and a stasis ulcer on the left ankle.
d. 75-year-old resident with congestive heart failure (CHF).
e. 70-year-old resident with chronic obstructive pulmonary disease (COPD).
Question 2The nurse is aware that the urge to defecate is increased peristalsis stimulated by the defecation reflex and the ______________________ reflex.
Fill in the blank with correct word.
Question 3To assess a suspected skin breakdown over the trochanter of a dark-complexioned African American fully, the nurse would _________________________. (Select all that apply.)
a. use a halogen light to examine the area.
b. palpate for local edema in the area.
c. touch the area to feel for changes in tissue temperature.
d. assess for localized pain.
e. press the area to test for blanching.
Question 4When performing a skin assessment for pressure ulcers on an older man who is bedridden and prefers to lie on his right side, the nurse will pay special attention to his _____________________________
_________. (Select all that apply.)
a. right ear.
b. lateral edge of right foot.
c. sacrum.
d. medial edge of left foot.
e. right scapula.
Question 5When the older man complains of a hard white patch that has developed on the side of his tongue, the nurse should:
a. request a dental consult to evaluate his dentures for adequate fit.
b. examine his teeth to assess for a lost filling, which has left sharp edges on his teeth.
c. request a medical consult for evaluation of a precancerous lesion.
d. provide frequent, warm, salt water rinses for his mouth.
Question 6The nurse explains that the purpose of the hydrocolloid dressing applied to a clean stage II pressure ulcer is to __________________________. (Select all that apply.)
a. dbride the ulcer.
b. prevent shear force trauma.
c. absorb the exudate.
d. prevent infection.
e. make an air-occlusive seal.
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