The nurse is assessing the skin of a client being admitted to the ...

[aabwk4]

The nurse is assessing the skin of a client being admitted to the long-term care facility from an acute care facility. A small blister is noted on the client's right heel. This is documented as:
 
  1. A stage I decubitus ulcer.
  2. A stage II decubitus ulcer.
  3. A stage III decubitus ulcer.
  4. A stage IV decubitus ulcer.

Question 2

The nurse is admitting a 79 year-old client to a long-term care facility, whose daughter is on her way to visit. The nursing care plan might include which of the following: Standard Text: Select all that apply.
 
  1. Risk for Ineffective Individual Coping
  2. Family expresses understanding of problems
  3. Situational transition
  4. Secretions are mobilized
  5. Risk for Impaired Parenting

[qytan]

Answer to Question 1

2
Rationale: A stage I ulcer is a nonblanchable redness of intact skin.

Answer to Question 2

1,2,3
Rationale: The client may have difficulty adjusting to the new residence.

[aabwk4]

Thank you!

[qytan]

Always glad to help...