A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Thick, dry, and dark area on bilateral heels.

Broken skin without evidence of undermining.

Defined area of persistent redness over bone.

Superficial sacral ulcer with defined margins.

Answer and Explanation

The Correct Answer is C

Choice A reason: A thick, dry, and dark area on bilateral heels may indicate the beginning stages of a pressure ulcer, but it is not the earliest sign. The earliest indication is usually a non-blanchable redness over a bony prominence.

Choice B reason: Broken skin without evidence of undermining could be a sign of a pressure ulcer, but it is not the earliest indication. The earliest sign is persistent redness over an area of pressure.

Choice C reason: A defined area of persistent redness over bone, especially if it does not blanch when pressed, is the earliest indication of a pressure ulcer. This stage is known as a Stage 1 pressure injury.

Choice D reason: A superficial sacral ulcer with defined margins indicates that a pressure ulcer has already developed and is not the earliest sign of its development.

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Free Nursing Study Resources

Correct Answer is ["2"]

Explanation

Step 1: We need to find out how many mL contain 10 mg of loratadine. Since 5 mg of loratadine is in 5 mL, we can set up a proportion to find out how many mL contain 10 mg.

So, 5 mg is to 5 mL as 10 mg is to X mL.

This gives us the equation: (5 mg ÷ 5 mL) = (10 mg ÷ X mL)

Step 2: Solving for X gives us X = (10 mg × 5 mL) ÷ 5 mg

Step 3: Simplifying gives us X = 10 mL

So, the client needs to take 10 mL of the loratadine suspension to get a dose of 10 mg.

Now, we need to convert this volume in mL to teaspoons, using the conversion factor you provided (1 teaspoon = 5 mL).

Step 4: We set up the conversion as follows: 10 mL × (1 tsp ÷ 5 mL)

Step 5: Simplifying gives us 2 tsp

So, the nurse should instruct the client to take 2 teaspoons of the loratadine suspension.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

Choice A Reason: Decreasing portion sizes can help manage calorie intake and contribute to weight loss, which is beneficial for individuals with prediabetes or diabetes. Proper portion control is also essential for maintaining blood sugar levels within the target range.
Choice B Reason: Avoiding potassium-rich foods is not a standard dietary recommendation for diabetes management unless the individual has a specific condition like kidney disease that requires potassium restriction.
Choice C Reason: Eating only plant-based foods is not necessary for diabetes management. While a plant-based diet can be part of a healthy eating plan, it is not required for all individuals with diabetes.
Choice D Reason: Choosing a well-rounded diet ensures that all necessary nutrients are included, which is important for overall health and can help manage blood sugar levels. A balanced diet for diabetes should include a variety of foods from all food groups.
Choice E Reason: Eliminating carbohydrates is not recommended for diabetes management. Carbohydrates are a necessary part of a healthy diet, and individuals with diabetes should focus on the type and amount of carbohydrates consumed rather than eliminating them entirely.
Choice F Reason: Replacing refined sugar with honey or molasses is not necessarily beneficial for diabetes management. While these are natural sweeteners, they still affect blood sugar levels and should be used in moderation.

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A client who is confined to a wheelchair as a result of a motorcycle accident is unable to feel pain or pressure from the waist down. Which finding provides the nurse with the earliest indication that the client is developing a pressure ulcer?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client has received a prescription for loratadine suspension, 10 mg to be taken orally once a day. The bottle is labeled as "Loratadine for Oral Suspension, USP 5 mg per 5 mL." How many teaspoons should the nurse instruct the client to take? (Please enter the numerical value only.)

Correct Answer is ["2"]

Explanation

Patient Data Exhibits Review H and P and laboratory results. Drag from the Word Choices to complete the sentence. For the nutrition education portion of the visit, the nurse focuses on dropdown and dropdown.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B"}

Explanation

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