A nurse is assisting in identifying clients on the medical surgical floor with skin problems. Which of the following are most likely to become chronic wounds?

Cluster of oral herpes sores

Abdominal surgical incision

Diabetic foot ulcer

Posterior scalp wound

Answer and Explanation

The Correct Answer is C

A. Cluster of oral herpes sores: Oral herpes sores typically heal within a few weeks and do not generally become chronic wounds unless there are complications or underlying immune system issues. They are more acute in nature and tend to resolve without becoming chronic.

B. Abdominal surgical incision: Surgical incisions are designed to heal within a specific timeframe, usually a few weeks to a couple of months, depending on the type of surgery and individual healing factors. While surgical wounds can sometimes have delayed healing or complications, they are not typically categorized as chronic wounds unless they fail to heal or become recurrent over an extended period.

C. Diabetic foot ulcer: Diabetic foot ulcers are highly prone to becoming chronic wounds due to the underlying pathology associated with diabetes, such as neuropathy (nerve damage), peripheral vascular disease (poor circulation), and impaired immune function. These factors can impair the normal healing process, leading to delayed healing, infection, and the potential for the wound to become chronic if not managed appropriately.

D. Posterior scalp wound: Scalp wounds can heal relatively quickly, especially with proper wound care and management. However, certain factors such as the size of the wound, depth, presence of infection, and underlying conditions can influence the likelihood of a scalp wound becoming chronic. In general, scalp wounds are less likely to become chronic compared to wounds in areas with higher risk factors, such as diabetic foot ulcers.

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Correct Answer is ["B","D"]

Explanation

A. Cool the burn with ice water:

Not recommended: Cooling a burn with ice water directly is not recommended as it can lead to further tissue damage and complications. Instead, the burn should be cooled with cool (not cold) running water for a limited time and then covered with a clean, dry cloth.

B. Administer opioid analgesics:

Recommended: Severe burns can cause excruciating pain, and opioid analgesics are often necessary to manage this pain effectively. However, the specific opioid, dosage, and route of administration should be determined by the healthcare provider based on the client's condition and pain level.

C. Administer systemic antibiotics:

Not routinely recommended: Unless there are signs of infection or the burn involves deep tissue damage, systemic antibiotics are not typically administered prophylactically for burn injuries. However, if there are signs of infection, such as redness, swelling, warmth, or drainage from the burn site, antibiotic therapy may be initiated based on culture and sensitivity results.

D. Administer benzodiazepines for anxiety management:

Considered: Severe burns can cause significant psychological distress and anxiety in patients. Benzodiazepines may be considered to manage acute anxiety and agitation in these situations. However, the decision to administer benzodiazepines should be made based on the client's overall condition, vital signs, and response to non-pharmacological interventions for anxiety.

E. Lay the head of the bed flat:

Not recommended: In a client with severe burns who is experiencing increased work of breathing, anxiety, and rapid breathing, it is generally more beneficial to elevate the head of the bed slightly (semi-Fowler's position) to improve respiratory mechanics and reduce anxiety-related respiratory distress.

A. Healthy middle-aged adult who never had chickenpox B. Older adult who lakes large doses of prednisone for a chronic condition C. Middle-aged adult who just started taking chemotherapy D. Nurse who recently received the first dose of varicella vaccine E. Young adult who is positive for the human immunodeficiency virus (HIV):

Correct Answer is ["B","C","E"]

Explanation

A. Healthy middle-aged adult who never had chickenpox:

This individual has not had chickenpox, which means they are susceptible to varicella-zoster virus (VZV) infection. If they contract herpes zoster (shingles), they are at risk for complications, although typically healthy adults are less likely to experience severe complications compared to immunocompromised individuals or older adults.

B. Older adult who takes large doses of prednisone for a chronic condition:

Chronic corticosteroid use, such as prednisone, can suppress the immune system and increase the risk of herpes zoster infection. Additionally, if herpes zoster develops in an older adult, they are at higher risk for complications such as postherpetic neuralgia (persistent nerve pain), bacterial superinfection of the rash, and dissemination of the virus.

C. Middle-aged adult who just started taking chemotherapy:

Chemotherapy suppresses the immune system, making individuals more susceptible to infections. If a person undergoing chemotherapy develops herpes zoster, they are at increased risk for serious complications due to their weakened immune response.

D. Nurse who recently received the first dose of varicella vaccine:

The varicella vaccine is designed to prevent chickenpox and reduce the risk of herpes zoster (shingles) in vaccinated individuals. Therefore, a nurse who received the varicella vaccine is less likely to experience serious complications from herpes zoster infection compared to those who are unvaccinated.

E. Young adult who is positive for the human immunodeficiency virus (HIV):

Individuals with HIV have a weakened immune system, increasing their susceptibility to infections, including herpes zoster. Moreover, herpes zoster in HIV-positive individuals can be more severe, prolonged, and may lead to complications such as disseminated herpes zoster, involving multiple organs and potentially becoming life-threatening.

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A nurse is assisting in identifying clients on the medical surgical floor with skin problems. Which of the following are most likely to become chronic wounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assisting in the care of a client who has severe burns. Exhibits Which of the following actions should the nurse take when caring for a client who has severe burns? Select all that apply.

Correct Answer is ["B","D"]

Explanation

Which people have the greatest risk for serious complications secondary to herpes zoster infection? Select all that apply.

Correct Answer is ["B","C","E"]

Explanation

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