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HESI Patient Review: Patients at Risk _ Complete solutions (answered) fall 2021

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HESI Patient Review: Patients at Risk Sally makes ongoing rounds, recommending prevention strategies and treatments for a wide variety of wounds, including pressure ulcers. A pressure ulcer is a/an:... A. ecchymotic area caused by tissue trauma B. localized area of tissue necrosis C. skin trauma caused by bacteria Which of the following contribute to Mr. Esserman's risk for development of pressure ulcers? Select all that apply (there are 5 correct answers). Hint A. Paralysis of arm and leg B. Loss of sensation C. Use of a trapeze on his bed D. Difficulty swallowing E. Slurred speech F. Urinary incontinence With Sally, you prepare to teach the Essermans about pressure ulcer prevention. Which of the following approaches is best? Hint A. Provide printed material "Preventing Pressure Ulcers: A Guide for Patients" B. Spend time with the Essermans explaining pressure ulcer prevention C. A combination of both of the above Which of the following modifications are recommended when teaching older persons? Select all that apply (there are 3 correct answers). A. Use of large print in printed materials B. Fluorescent lighting should be used when printed materials are read C. Long and detailed explanations may be necessary D. Presentation and discussion should be slow and unrushed E. A slightly louder, low-pitched speaking voice may be needed What should the Essermans be taught about moving and positioning? Select all that apply (there are 2 correct answers). HintA. Applying a liberal amount of lotion and powder to Mr. Esserman's skin will make position changes easier B. A soft sheet or towel, applied under Mr. Esserman, can be used to assist with turning C. When moving Mr. Esserman, the person doing the moving should bend his/her knees D. Use of a donut-shaped cushion at the lower back is recommended You teach the Essermans that when Mr. Esserman is in bed his position should be changed at least every: A. 15 minutes B. 30 minutes C. 2 hours D. 4 hours When assessing a reddened area, it is important that it be checked for: Select all that apply (there are 2 correct answers). Hint A. odor B. pitting C. blanching D. sensation When Mr. Esserman is in a chair, his weight should be shifted every: A. 15 minutes B. 30 minutes C. 1 hour D. 2 hours With regard to the reddened area, which of the following is indicated? Hint A. The reddened skin at the sacral area should be massaged with lotion B. Plans should be made to keep the area free of pressure C. A wet-to-dry dressing can be applied D. The area should be cleansed with hydrogen peroxideWhich of the following techniques can be used to determine if the air-filled static overlay on Mr. Esserman's bed is adequate in reducing pressure? Hint A. With Mr. Esserman in bed, place a hand between the overlay and Mr. Esserman B. With Mr. Esserman in bed, place a hand between the mattress and the overlay Mr. Esserman needs nutrients of all types to provide calories and energy, but especially protein. What strategies do you appropriately encourage Mrs. Esserman to use in providing extra protein in her husband’s diet? Select all that apply (there are 2 correct answers). Hint A. Provide finely ground meat (such as chicken or beef) at each meal B. At each meal, feed protein-rich foods first C. Offer yogurt or seasoned soft-cooked scrambled eggs to provide protein D. Offer Mr. Esserman a high-calorie supplement, such as Sustacal, as one of his mealseach day Mrs. Esserman asks, "How will I know if my husband is getting one of these bedsores?" Which of the following advice is appropriate? A. "Check your husband's skin for open areas once a week." B. "When your husband's position is changed, check for reddened areas." C. "We'll check your husband's skin weekly and let you know." Using the Braden Scale, Mr. Espreaux's sensory perception risk score is determined to be: Hint A.1 B.2 C.3 D.4 Using the Braden Scale, Mr. Espreaux's moisture risk score is determined to be: Hint A.1 B.2 C.3 D.4Using the Braden Scale, Mr. Espreaux's activity risk score is determined to be: Hint A.1 B.2 C.3 D.4 Using the Braden Scale, Mr. Espreaux's mobility risk score is determined to be: Hint A.1 B.2 C.3 D.4 Using the Braden Scale, Mr. Espreaux's nutrition risk score is determined to be: Hint A.1 B.2 C.3 D.4 Using the Braden Scale, Mr. Espreaux's friction and shear risk score is determined to be: Hint A.1 B.2 C.3 Mr. Espreaux's total pressure sore risk score using the Braden Scale is 15. This means that he is: A. low risk for developing a pressure ulcer B. high risk for developing a pressure ulcer Using the Braden Scale, which of the following scores would indicate that a person was at low risk for developing a pressure ulcer? HintA. 23 B. 15 C. 12 D. 7 A written care plan for pressure ulcer prevention, which includes a repositioning schedule, is established for Mr. Espreaux. Important components include: Select all that apply (there are 3 correct answers). A. repositioning every four hours B. use of support surfaces C. use of positioning devices D. having Mr. Espreaux shift his weight periodically In assessing Mr. Espreaux, because he is African-American and dark-skinned, which of the following indicators of a Stage I pressure ulcer apply? Select all that apply (there are 2 correct answers). A. Erythema B. Warmth to touch C. Induration Sally reminds the nurses caring for Mr. Espreaux about the importance of staging any pressure ulcers. Which of the following are true about staging? Select all that apply (there are 3 correct answers). A. Pressure ulcers should be staged using a staging system B. Pressure ulcers should be staged when discovered C. Staging should be done by a Certified Wound, Ostomy, and Continence Nurse (CWOCN) / Certified Wound Care Nurse (CWCN) D. Staging is a primary criterion that guides treatment Which of the following wound care dressing choices are acceptable for this Stage II pressure ulcer? Select all that apply (there are 2 correct answers). Hint A. An alginate dressing B. A sacral specific hydrocolloid dressing C. A transparent film membrane dressing D. A wet-to-dry gauze dressingWhen Mrs. Correo was first admitted, Sally correctly: Hint A. staged her pressure ulcer as Stage I B. staged her pressure ulcer as Stage II C. staged her pressure ulcer as Stage III D. staged her pressure ulcer as Stage IV E. determined that the ulcer was not stageable at the time When necrotic tissue is present, it must be removed before wound healing can occur. The process of removing necrotic tissue is called: A. granulation B. debridement C. compression D. necrolysis What type of dressing is Sally appropriately using on this pressure ulcer now? A. Transparent film B. Hydrocolloid C. Alginate What type of solution is used to safely clean Mrs. Correo's pressure ulcer before applying a new dressing? A. Normal saline B. Povidone-iodine (Betadine) C. Hydrogen peroxide D. Acetic acid Using sterile normal saline, Mrs. Correo's wound is cleansed: Hint A. by dabbing the wound with moistened gauze B. using a bulb syringe C. using a 35 mL syringe with a 19-gauge needleWhich of the following observations of peri-wound skin during a dressing change procedure would indicate a need to modify the wound care approach? Select all that apply (there are 2 correct answers). A. The skin around the wound is moist, soft, and wrinkled B. The skin around the wound is dry and pink C. The wound bed is moist and the dressing is wet when changed D. The wound bed is moist and the dressing is saturated when changed [Show More]

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