Answer to Question 1
C
Assess all surfaces exposed to casts, cloth restraints, bandages and dressings, tubing, or orthopedic braces. An external device applied to or around the skin exerts pressure or friction on the skin, leading to skin impairment. When restricted from moving, dependent body parts are exposed to pressure that reduces circulation to affected tissues. Know which patients require assistance to turn and change positions. Patients with limited caloric and protein intake develop impaired or delayed wound healing. Keeping the blood pressure artificially low may decrease arterial blood supply, leading to ischemia and breakdown.
Answer to Question 2
B
Feedback
A To determine learning needs, the nurse should assess the patient's previous knowledge level. However, this would not be the most important factor for the nurse to assess first.
B If a person does not want to learn, it is unlikely that learning will occur. Motivation is the first factor the nurse should assess before teaching.
C Assessing a patient's financial resources for obtaining equipment is important; however, it is not the most important factor for the nurse to assess first.
D Assessing the patient's physical and cognitive ability to learn is important. However, it is not the most important factor for the nurse to assess first.
The patient interview often requires note taking.
The nurse conducts the health history as the first step in the nursing assessment
external structure of female reproductive system
Position of patient following seizure
A medical assistant helps a patient walk with a gait belt.
Nurse using a stethoscope