Answer to Question 1
B
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A Poor nutrition is a risk factor for developing a pressure ulcer but is not the primary risk factor for this patient.
B The patient who has right-sided paralysis is at increased risk for a pressure ulcer developing because of immobility. When restricted from moving freely, dependent body parts are exposed to pressure, reducing circulation to affected body parts. The inability to turn or change position increases the risk for pressure ulcers.
C The patient is not identified as having reduced hydration.
D Skin secretions increase the risk for developing a pressure ulcer; however, this patient's greatest risk factor is having impaired mobility.
Answer to Question 2
C
During the proliferative phase, the wound fills with granulation tissue (including collagen for-mation), the wound contracts, and the wound is resurfaced by epithelialization.
Primary intention is not a phase of wound healing. Wounds that heal by primary intention have minimal tissue loss, such as a surgical wound. The edges are approximated, and the risk of infec-tion is low.
During the inflammatory phase, platelets gather to stop bleeding, a fibrin matrix forms, and white blood cells reach the wound, clearing it of debris.
Secondary intention is not a phase of wound healing. Wounds that heal by secondary intention have loss of tissue, such as a pressure ulcer. The wound is left open until it becomes filled by scar tissue.
The nurse assists the patient in reflecting on his feelings
Testing Visual Fields by Confrontation: The nurse and patient should be approximately at an eye to e
Application of an ostomy bag or pouch: B, An ostomy nurse applying an ostomy bag to a stoma;
Left sided heart failure
Teaching an illterate patient
Patient teaching: ear assessment