The nurse assesses a wound with exudate. What should be included when documenting the exudate? (Select all that apply.)

Color

Odor

Heat

Consistency

Amount

Answer and Explanation

Correct Answer : A,B,D,E

Choice A reason: Color is a characteristic of exudate that should be included when documenting it. Color can indicate the type and severity of the wound infection or inflammation. For example, yellow or green exudate may indicate a bacterial infection, while red or brown exudate may indicate bleeding or necrosis.

Choice B reason: Odor is a characteristic of exudate that should be included when documenting it. Odor can indicate the presence and type of microorganisms in the wound. For example, a foul or putrid odor may indicate anaerobic bacteria, while a sweet or fruity odor may indicate pseudomonas.

Choice C reason: Heat is not a characteristic of exudate that should be included when documenting it. Heat is a sign of inflammation that can be assessed by palpating the skin around the wound, not by observing the exudate. Heat does not directly reflect the quality or quantity of the exudate.

Choice D reason: Consistency is a characteristic of exudate that should be included when documenting it. Consistency can indicate the viscosity and composition of the exudate. For example, thin or watery exudate may indicate a serous or serosanguineous fluid, while thick or creamy exudate may indicate a purulent or fibrinous fluid.

Choice E reason: Amount is a characteristic of exudate that should be included when documenting it. Amount can indicate the extent and stage of the wound healing process. For example, a large amount of exudate may indicate a high level of inflammation or infection, while a small amount of exudate may indicate a low level of inflammation or infection.

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Correct Answer is B

Explanation

Choice A reason: "Tomorrow will be better." is not a statement that demonstrates empathy, but rather one that demonstrates false reassurance or denial. False reassurance or denial is a communication barrier that dismisses or minimizes the client's feelings or concerns, and offers unrealistic or vague promises that may not be fulfilled. False reassurance or denial can make the client feel invalidated, misunderstood, or hopeless.

Choice B reason: "This must be hard news to hear. Tell me more about it." is a statement that demonstrates empathy, which is the ability to understand and share the feelings of another person. Empathy is a communication skill that acknowledges and validates the client's feelings or concerns, and invites the client to express and explore them further. Empathy can make the client feel supported, respected, and empowered.

Choice C reason: "What is your biggest fear about this diagnosis?" is not a statement that demonstrates empathy, but rather one that demonstrates probing or prying. Probing or prying is a communication barrier that asks intrusive or inappropriate questions that may make the client feel uncomfortable, defensive, or threatened. Probing or prying can make the client feel violated, judged, or pressured.

Choice D reason: "I believe you can overcome this because I've seen how strong you are." is not a statement that demonstrates empathy, but rather one that demonstrates stereotyping or labeling. Stereotyping or labeling is a communication barrier that assigns a fixed or generalized characteristic to a person or a situation, without considering the individuality or uniqueness of the person or the situation. Stereotyping or labeling can make the client feel objectified, devalued, or misunderstood.

A. These drugs kill the virus B. Only certain licensed drugs are effective C. A few missed doses per month are OK D. These drugs inhibit viral replication

Correct Answer is D

Explanation

Choice A reason: These drugs kill the virus is not true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it is inaccurate and misleading. Antiretroviral drugs do not kill the virus, but rather block or interfere with the enzymes or proteins that the virus needs to replicate or integrate into the host cells. Antiretroviral drugs can reduce the viral load, which is the amount of virus in the blood, but they cannot eliminate the virus completely.

Choice B reason: Only certain licensed drugs are effective is not true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it is vague and incomplete. Antiretroviral drugs are licensed and approved by the regulatory authorities, such as the Food and Drug Administration (FDA), based on their safety and efficacy. However, not all licensed drugs are equally effective for all people with HIV, as the virus can develop resistance or mutation to some drugs over time. Therefore, the choice and combination of antiretroviral drugs may vary depending on the individual's viral genotype, drug history, and drug interactions.

Choice C reason: A few missed doses per month are OK is not true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it is incorrect and dangerous. Antiretroviral drugs require strict adherence and compliance, which means taking the drugs exactly as prescribed, without missing or skipping any doses. A few missed doses per month are not OK, as they can reduce the effectiveness of the drugs and increase the risk of viral resistance or mutation, which can lead to treatment failure or disease progression.

Choice D reason: These drugs inhibit viral replication is true about antiretroviral drugs used to treat human immunodeficiency virus (HIV), because it describes the mechanism and outcome of the drugs. Antiretroviral drugs inhibit viral replication, which means they prevent or slow down the multiplication or reproduction of the virus. Antiretroviral drugs can inhibit viral replication by targeting different stages of the viral life cycle, such as reverse transcription, integration, or maturation. Antiretroviral drugs can improve the immune function and quality of life of people with HIV.

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The nurse assesses a wound with exudate. What should be included when documenting the exudate? (Select all that apply.)

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