The admitting nurse gives the new long-term care facility resident a score of 20 on both the Norton Risk Assessment Scale and the Braden Scale for Predicting Pressure Sore Risk. These scores indicate that the resident has
a. a high probability of developing a pressure ulcer.
b. a moderate risk of developing a pressure ulcer.
c. a low risk of developing a pressure ulcer.
d. at least one pressure ulcer at the time of admission.
Question 2On the admission assessment of an 80-year-old to a long-term care facility, the nurse notes that the resident's toenails are dark, thick, and brittle; extremely misshapen; and growing at an angle from the toe.
What does the nurse suspect has caused the changes in the nails?
a. Fungal infection of the nails
b. Ram's horn nails
c. Ingrown nails
d. Expected age-related changes in the nails
Question 3What would be the most effective intervention to prevent pressure ulcers in the bedridden patient?
a. Perform skin assessment every day.
b. Use a draw sheet to move the patient.
c. Change the patient's position every 2 hours.
d. Remove wet bed linens promptly.
Question 4An 80-year-old woman complains of pruritus from dry skin. What would be an appropriate bathing schedule for the patient?
a. A hot shower every night before going to bed.
b. A cool shower every morning using a detergent soap.
c. A soak in a warm sudsy bath, leaving a film of soap on the skin.
d. One shower a week, with sponge baths in between.
Question 5What is the cause of progressively graying hair?
a. Decreased production of melanin
b. Altered blood circulation to the scalp
c. Decreased density of hair
d. Environmental factors
Question 6The nurse assesses an area of skin on the patient's upper thigh that is different in appearance than the surrounding skin. What documentation would be the most informative?
a. Red area on upper right thigh. Patient denies discomfort
b. Erythematous scaly patch 2 2 cm on lateral aspect of right thigh. Patient denies pain
c. Painless red patch on right thigh 2 2 cm
d. Medium-size red scaly patch on right thigh. 0 drainage. 0 pain
Question 7The 80-year-old woman newly admitted to a long-term care facility complains of intense itching in her axillae and antecubital fossa. There are small red lesions in linear patterns. What condition does the nurse suspect?
a. Rosacea
b. Keratosis
c. Pruritus
d. Scabies