The client states, "Why am I getting protein supplements while I'm healing from a bed sore?" What is the best response by the nurse?
"Because it is easy to digest."
"If you don't like it, you don't have to take it."
"These supplements have nothing to do with your wound."
"Protein has amino acids that promote wound healing."
The Correct Answer is D
Choice A reason: "Because it is easy to digest." is not the best response by the nurse. This is not a valid reason for giving protein supplements to a client with a bed sore. Protein supplements may or may not be easy to digest depending on the type and amount of protein and the client's digestive system. The ease of digestion is not the main goal of protein supplementation.
Choice B reason: "If you don't like it, you don't have to take it." is not the best response by the nurse. This is a dismissive and unprofessional response that does not address the client's question or concern. Protein supplements are prescribed for a reason and the client should be educated on the benefits and risks of taking or refusing them. The nurse should also respect the client's preferences and choices and offer alternatives if possible.
Choice C reason: "These supplements have nothing to do with your wound." is not the best response by the nurse. This is a false and misleading statement that contradicts the evidencebased practice of wound care. Protein supplements have a lot to do with wound healing as they provide the essential nutrients for tissue repair and regeneration. Protein deficiency can impair wound healing and increase the risk of infection and complications.
Choice D reason: "Protein has amino acids that promote wound healing." is the best response by the nurse. This is a factual and informative statement that explains the rationale for giving protein supplements to a client with a bed sore. Protein is composed of amino acids, which are the building blocks of cells and tissues. Amino acids are involved in various processes of wound healing, such as collagen synthesis, angiogenesis, and immune response. Protein supplementation can enhance wound healing and prevent protein malnutrition.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Nociceptive pain is not the type of pain that the client is experiencing. Nociceptive pain is caused by the stimulation of nociceptors, which are sensory receptors that detect tissue damage or potential harm. Nociceptive pain is usually localized, sharp, throbbing, or aching. It is associated with injuries such as cuts, burns, sprains, or fractures. The client's pain is not caused by any tissue damage or harm in the distal part of the amputated limb, as there is no tissue left there.
Choice B reason: Neuropathic pain is the type of pain that the client is experiencing. Neuropathic pain is caused by the damage or dysfunction of the nervous system, such as the peripheral nerves, the spinal cord, or the brain. Neuropathic pain is usually chronic, burning, shooting, or tingling. It is associated with conditions such as diabetes, shingles, stroke, or amputation. The client's pain is caused by the disruption of the nerve signals from the amputated limb, which creates a phantom sensation of pain in the missing part.
Choice C reason: Cutaneous pain is not the type of pain that the client is experiencing. Cutaneous pain is caused by the stimulation of the cutaneous receptors, which are sensory receptors that detect touch, temperature, or pressure on the skin. Cutaneous pain is usually superficial, brief, or pricking. It is associated with stimuli such as pinching, scratching, or cold. The client's pain is not caused by any touch, temperature, or pressure on the skin of the distal part of the amputated limb, as there is no skin left there.
Choice D reason: Visceral pain is not the type of pain that the client is experiencing. Visceral pain is caused by the stimulation of the visceral receptors, which are sensory receptors that detect stretch, inflammation, or ischemia in the internal organs. Visceral pain is usually deep, dull, or cramping. It is associated with conditions such as appendicitis, pancreatitis, or bowel obstruction. The client's pain is not caused by any stretch, inflammation, or ischemia in the internal organs of the distal part of the amputated limb, as there are no organs left there.
Correct Answer is D
Explanation
Choice A reason: This is not the priority assessment, but it is an important assessment for a client with a femur fracture. Pain is the unpleasant sensation that results from tissue damage or inflammation. Pain can affect the client's physical and psychological wellbeing and interfere with their recovery. The nurse should assess the client's pain level, location, quality, and duration using a valid and reliable pain scale. The nurse should also provide pain relief measures, such as medication, ice, elevation, or distraction, as ordered and as needed.
Choice B reason: This is not the priority assessment, but it is a relevant assessment for a client with a femur fracture. Medication history is the record of the drugs that the client is currently taking or has taken in the past, including prescription, overthecounter, herbal, or recreational drugs. Medication history can help the nurse identify any potential drug interactions, allergies, or contraindications that may affect the client's treatment and recovery. The nurse should ask the client about their medication history and document it accurately and completely.
Choice C reason: This is not the priority assessment, but it is a helpful assessment for a client with a femur fracture. Socioeconomic status is the measure of the client's income, education, occupation, and social class. Socioeconomic status can influence the client's access to health care, ability to afford treatment, compliance with therapy, and support system. The nurse should assess the client's socioeconomic status and provide appropriate referrals, resources, or assistance as needed.
Choice D reason: This is the priority assessment for a client with a femur fracture. Pedal pulses are the pulses that can be felt in the feet, such as the dorsalis pedis or the posterior tibial pulse. Pedal pulses can indicate the blood flow and perfusion to the lower extremities, which can be compromised by a femur fracture. A femur fracture can cause bleeding, swelling, or pressure that can reduce or obstruct the blood supply to the feet, leading to ischemia, necrosis, or gangrene. The nurse should assess the client's pedal pulses regularly and report any changes, such as absent, weak, or thready pulses. The nurse should also monitor the client's skin color, temperature, sensation, and movement in the feet.
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