An older adult patient with diabetes recently moved into an ...

[shofmannx20]

An older adult patient with diabetes recently moved into an assisted living apartment to have assistance with bathing and housework. During a bath, the assistive nursing personnel noticed that there was a large blister on the patient's right heel.
 
  The patient denies knowledge of having injured self. It was reported to the nurse who correctly documented it as what stage of a pressure ulcer? a. Stage I
  b. Stage II
  c. Stage III
  d. Stage IV

Question 2

A mother of five children is admitted to the hospital for abdominal pain. The nurse asks a series of questions before performing a physical assessment. The patient answers the questions.
 
  When asking the patient some other questions, the patient's spouse starts to answer. As the admission process progresses and the nurse gathers subjective data, the nurse requests that the patient answer the next questions. What is the rationale for the nurse's behavior? a. The patient is exhibiting confusion.
  b. The spouse is being obnoxious.
  c. The patient is the best source of information.
  d. The spouse is too controlling.

[ally]

Answer to Question 1

B
Stage II: Partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough; may also present as an intact or open/ruptured serum-filled blister
Stage I: Intact skin with nonblanchable redness of a localized area, usually over a bony prominence
Stage III: Full-thickness tissue loss; subcutaneous fat may be visible, but bone, tendon, or muscle is not exposed; slough may be present but does not obscure the depth of tissue loss; may include undermining and tunneling
Stage IV: Full-thickness tissue loss with exposed bone, tendon, or muscle; slough or eschar may be present; often includes undermining and tunneling

Answer to Question 2

C
A patient is usually the best source of information. A patient who is alert and answers questions appropriately provides the most accurate information about health care needs, lifestyle patterns, present and past illnesses, perception of symptoms, and changes in activities of daily living. There is no evidence in the scenario to indicate confusion on the patient's part or that the spouse was obnoxious or too controlling. The nurse needs more data before saying the spouse is obnoxious or controlling.