The nurse is assessing the client's stage III decubiti of the ...

[Bob-Dole]

The nurse is assessing the client's stage III decubiti of the coccyx. In measuring the depth and width of the
 
  wound, the nurse notes that the wound is beefy red and grainy, and the depth has decreased by 2 mm but the width has not changed.
 
  The nurse interprets this finding as the wound
  A) progressing positively toward healing.
  B) not healing properly.
  C) no longer at risk for infection.
  D) about to slough off tissue.

Question 2

The nurse is planning to teach a nursing assistant to use the hand-over-hand method to assist an older patient with dementia in performing mouth care. Which instruction should the nurse provide to the assistant?
 
  1. Place a hand over the patient's hand and guide the patient to perform mouth care.
  2. Use lemon and glycerin swabs to cleanse the gums around the teeth in the front.
  3. Speak sternly and instruct the patient to open the mouth and brush the teeth quickly.
  4. Carefully place two fingers of a gloved hand in the patient's mouth to access the back teeth.

[ilianabrrr]

Answer to Question 1

A

Answer to Question 2

1
Rationale: The hand-over-hand method involves the caregiver placing a hand over the patient's hand and guiding the patient in performing the activity.