A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy.She has a pressure area on her coccyx measuring 5 cm by 3 cm.The area is covered with 100% eschar.What would the nurse identify this as?

A) Stage II pressure ulcer
B) Stage III pressure ulcer
C) Stage IV pressure ulcer
D) Unstageable pressure ulcer

A nursing instructor is guiding nursing students on best practices for interviewing patients.Which of the following comments by a student would indicate the need for further instruction?

A) "My patient is a young adult, so I plan to talk to her without her parents in the room."
B) "Because my patient is old enough to be my grandfather, I will call him Mr."
C) "When reading my patient's health record, I thought of a few questions to ask."
D) "When I give my patient his pain medication, I will have time to ask questions."

When a person genuinely believes he is having a heart attack or on the verge of death,but there is nothing physically wrong with that person,he is having:

A) a manic episode.
B) a panic attack.
C) an obsession.
D) a psychotic episode.

The nurse is completing an assessment of the patient's skin's integrity. Which assessment is the $\mathbf{priority}$ ?

A) Pressure points
B) Breath sounds
C) Bowel sounds
D) Pulse points

Mrs.Jhang,56,has an incision requiring a complex dressing change.The client is scheduled to be discharged home and the wound will require continued dressings at home.Which statement by the client indicates a need to postpone teaching?

A) "It's going to take time for me to understand this whole thing."
B) "Let's make sure my spouse is around before you start explaining."
C) "I wish my doctor had explained this in more depth."
D) "I'm feeling nauseous,but go ahead and start anyway."

The nurse is preparing an older-adult patient's evening medications. Which treatment will the nurse recognize as relatively safe for difficulty sleeping in older adults?

A) Ramelteon (Rozerem)
B) Benzodiazepine
C) Antihistamine
D) Kava