Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus.
The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

Cholestrol level

Prealbumin level

History of malnutrition

History of diabetes mellitus

History of hyperlipidemia)

Answer and Explanation

Correct Answer : B,C,D

A. Cholesterol level:

While hyperlipidemia (elevated cholesterol levels) is associated with cardiovascular disease, it is not a direct factor affecting wound healing. Cholesterol levels primarily impact vascular health and are not directly related to the cellular and tissue processes involved in wound repair.

B. Prealbumin level:

Prealbumin is a protein that reflects recent dietary intake and nutritional status. Low prealbumin levels can indicate malnutrition, which is associated with delayed wound healing. Adequate protein intake is crucial for tissue repair and wound healing.

C. History of malnutrition:

Malnutrition is a significant risk factor for delayed wound healing. Adequate nutrition is essential for the body to carry out the processes involved in wound healing, including cell proliferation, collagen synthesis, and immune function.

D. History of diabetes mellitus:

Diabetes mellitus can impair wound healing due to factors such as reduced blood flow, impaired immune response, and neuropathy. Elevated blood sugar levels in diabetes can interfere with the normal healing processes, leading to delayed wound healing.

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Correct Answer is C

Explanation

A. Place the sterile field at the level of the nurse's hips:

This is incorrect. The sterile field should be placed at a waist or chest level to maintain its sterility. Placing it at the level of the nurse's hips increases the risk of contamination from airborne particles, clothing, or unsterile surfaces.

B. Pour liquids into containers outside the sterile field:

This is incorrect. Pouring liquids into containers outside the sterile field may lead to contamination. All actions involving sterile items should be performed within the sterile field to maintain its integrity and prevent the introduction of microorganisms.

C. Hold bottles of sterile solution with the label in the palm of the hand:

Hold bottles of sterile solution with the label in the palm of the hand:This is correct. This prevents label from becoming wet and illegible.

D. Open the outermost flap of the sterile kit toward the body:

Open the outermost flap of the sterile kit toward the body:This is incorrect. When opening a sterile kit, the nurse should open the outermost flap first and away from the body. This minimizes the risk of reaching over the sterile field, reducing the chance of accidental contamination.

A. "You shouldn't worry about the future so you can concentrate on getting well." B. "if you work hard on your physical therapy, you won't need to worry." C. "You're concerned about what will happen when you leave the hospital?" D. "Why are you concerned even though everyone is here to help you?"

Correct Answer is C

Explanation

A. "You shouldn't worry about the future so you can concentrate on getting well.":

This response dismisses the client's concerns and may make them feel invalidated. It implies that their worry is not justified and may hinder open communication about their feelings.

B. "If you work hard on your physical therapy, you won't need to worry.":

While encouragement and motivation are essential, this response may come across as minimizing the client's emotional concerns. It focuses solely on the physical aspect of recovery and does not address the broader emotional and psychological aspects of the client's worry about the future.

C. "You're concerned about what will happen when you leave the hospital?":

This response reflects active listening and empathy, acknowledging the client's expressed concern and inviting further discussion. It allows the client to express their feelings and concerns about the future, fostering a therapeutic nurse-client relationship.

D. "Why are you concerned even though everyone is here to help you?":

This response might be perceived as judgmental or dismissive of the client's feelings. It could make the client feel defensive and hesitant to share their concerns. It does not encourage open communication or exploration of the client's emotions.

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Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus. The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

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Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus.
The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.