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images.jfif.jpg The nurse is completing a skin assessment and notes the following. What stage would the nurse chart for this wound?

Client reports chronic tearing, eye irritation, and a sensation of “something in the eye.”   On assessment, the nurse notes that the lower eyelid is turned inward and the cornea appears slightly reddened. Which action should the nurse take first? Eye Disorder

A client is admitted to the hospital with limited mobility following a stroke. The client is frequently repositioned while in bed and is receiving physiotherapy to overcome right-sided lower extremity weakness. The nurse observes that the client often slides down in the bed, requiring frequent repositioning, and the absorbent pad under the client is wet with urine between changes. The client is being tube-fed and tolerating well. Based on this scenario, what factors does the nurse identify as putting the client at risk for skin breakdown? Select all that apply.

A community health nurse has been invited to speak to a group of older adults at the local community center about the importance of health promotion in this population. Which action would be most appropriate?

The nurse encourages the family of a terminally ill client to stay in the room because of approaching death. What did the nurse assess to make this clinical determination? 

An elderly client admitted for dizziness often asks the nurse to repeat herself, appears frustrated and looks away during conversation, and often answers questions inappropriately. Which actions, by the nurse, would best improve communication?Select all that apply.

A nurse is assessing an older adult and a family caregiver. Which statement by a family caregiver would lead the nurse to suspect elder abuse?

A client with type 2 diabetes mellitus has received treatment with 4 ounces of orange juice for a hypoglycemic episode. Accucheck has risen to 90 mg/dL. Lunch is not scheduled for another two hours. How should the nurse proceed to ensure that hypoglycemia does not reoccur?

A client who is edentulous tells the nurse, “I don’t bother going to the dentist anymore since I don’t have any teeth.” Which response by the nurse demonstrates appropriate understanding of oral health needs for this client?

Client presents with complaints of excessive fatigue, weight gain, constipation and cold intolerance. What lab test should the nurse anticipate being ordered by the physician?