A nurse is caring for a client in a wound center.
Click to highlight the findings that indicate therapy has been ineffective. To deselect a finding, click on the finding again.
Nurses' Notes
Today:
Client presents for evaluation of wound vac therapy that was applied to surgical wound on their left knee 1 week ago.
Cilent rates pain as 8 on a scale of 0 to 10 in their left knee. Client reports no relief with pain medications.
Respirations even and nonlabored. Heart rate regular and fast. Abdomen soft and nondistended.
Left knee wound vac dressing removed. Left knee wound is 3 cm by 2 cm with 1 cm depth, Wound bed vascular with some approximation of the edges. Mild purulent drainage noted.
Cilent rates pain as 8 on a scale of 0 to 10 in their left knee
Client reports no relief with pain medications
Left knee wound is 3 cm by 2 cm with 1 cm depth
Wound bed vascular with some approximation of the edges
Mild purulent drainage noted
The Correct Answer is ["A","B","C","E"]
Rationale:
- Client rates pain as 8 on a scale of 0 to 10 in their left knee. Client reports no relief with pain medications. The client’s pain has worsened from 4/10 despite pain medication, indicating the current pain management approach is ineffective, and the wound may not be healing as expected.
- Mild purulent drainage noted: The presence of purulent drainage is a sign of infection, further indicating that the wound vac therapy has not been successful in preventing or managing infection at the wound site.
- Left knee wound is 3 cm by 2 cm with 1 cm depth, compared to 2 cm by 2 cm with 1 cm depth one week ago: The increase in wound sizefrom 2cm by 2 cm to 3 cm by 2 cm suggests that the wound vac therapy is not promoting healing effectively, leading to a failure of wound closure.
Rationale for Incorrect Choices:
- Wound bed vascular with some approximation of the edges: The wound bed being vascular with some approximation of the edges indicates that there is some healthy tissue and the edges of the wound are coming together. This suggests that some healing is occurring, although it may be slower than expected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Keep eyes open during relaxation therapy: Keeping the eyes closed is typically recommended during relaxation and meditation to help focus and avoid external distractions. Keeping the eyes open can interfere with the ability to achieve a relaxed state.
B. Tighten and relax muscles during relaxation therapy: Progressive muscle relaxation involves tightening and then relaxing each muscle group to help reduce tension and promote relaxation. This technique helps increase body awareness and alleviate stress.
C. Plan to meditate immediately after meals: Meditating immediately after meals can be uncomfortable because it may cause indigestion or distract from the relaxation process. It’s better to meditate when the stomach is not full to avoid discomfort.
D. Take short and shallow breaths when meditating: Deep and slow breathing is a key component of meditation and relaxation techniques. Short and shallow breaths can increase stress rather than reduce it, as they may activate the body's "fight or flight" response. Deep breathing helps activate the parasympathetic nervous system, which promotes relaxation.
Correct Answer is A
Explanation
A. The client reports frequently having a headache in the morning: Frequent morning headaches can indicate sleep-related issues such as sleep apnea or bruxism (teeth grinding), both of which can significantly affect sleep quality and overall health.
B. The client reports having vivid dreams about their childhood: Vivid dreams can occur naturally, especially during rapid eye movement (REM) sleep. Although they may be unusual, they are not typically a cause for concern.
C. The client reports taking 30 min to fall asleep on average: Taking up to 30 minutes to fall asleep is within normal limits for most people. This is not a concerning finding and does not necessarily require reporting unless the client is experiencing other sleep disturbances.
D. The client reports sleeping about 7 hr on average: Sleeping around 7 hours per night is considered within the normal range for most adults. This is generally adequate sleep, and there is no indication of a significant issue that would require reporting to the provider.
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