The nurse assesses a wound with exudate. What should be included when documenting the exudate? (Select all that apply.)
Color
Odor
Heat
Consistency
Amount
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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Related Questions
Correct Answer is D
Explanation
Choice A reason: Heberden's nodes are not a symptom of lupus. Heberden's nodes are bony swellings that form on the distal interphalangeal joints of the fingers. They are a sign of osteoarthritis, which is a degenerative joint disease that causes pain, stiffness, and reduced mobility.
Choice B reason: Chvostek's sign is not a symptom of lupus. Chvostek's sign is a facial twitch that occurs when the facial nerve is tapped near the ear. It is a sign of hypocalcemia, which is a low level of calcium in the blood. Hypocalcemia may be caused by various conditions, such as hypoparathyroidism, vitamin D deficiency, or renal failure.
Choice C reason: OsgoodSchlatter's disease is not a symptom of lupus. OsgoodSchlatter's disease is a condition that affects the growth plate of the tibia, which is the shin bone. It causes pain, swelling, and tenderness below the knee. It is common in adolescents who are active in sports that involve running, jumping, or bending the knee.
Choice D reason: Butterfly rash is a classic symptom of lupus. Butterfly rash is a malar rash that appears across the cheeks and the bridge of the nose. It is a common sign of systemic lupus erythematosus (SLE), which is an autoimmune disease that causes inflammation and damage to various organs and tissues. The rash may flare up or fade depending on the disease activity and exposure to sunlight.
Correct Answer is A
Explanation
Choice A reason: A client with leukemia is a susceptible host most at risk for infection. Leukemia is a type of cancer that affects the blood cells, especially the white blood cells, which are responsible for fighting infections. Leukemia causes the production of abnormal and immature white blood cells that cannot function properly and crowd out the normal ones. This leads to a condition called leukopenia, which is a low level of white blood cells. Leukopenia makes the client more vulnerable to infection by reducing the immune system's ability to defend against pathogens.
Choice B reason: A child who is immunized is not a susceptible host most at risk for infection. Immunization is a process that stimulates the immune system to produce antibodies against a specific disease. Immunization protects the child from getting infected by the disease or reduces the severity of the infection if it occurs. Immunization also prevents the spread of the disease to other people who are not immunized or who are immunocompromised.
Choice C reason: A 60yearold client is not a susceptible host most at risk for infection. Age is a factor that may influence the susceptibility to infection, but it is not the most important one. Older adults may have a weaker immune system due to aging, chronic diseases, or medications, but they may also have a stronger immune memory due to previous exposure to pathogens. The risk of infection in older adults depends on their overall health status, lifestyle, and preventive measures.
Choice D reason: A hospitalized 35yearold client is not a susceptible host most at risk for infection. Hospitalization is a factor that may increase the exposure to infection, but it is not the most significant one. Hospitalized clients may encounter various sources of infection, such as health care workers, other clients, medical equipment, or invasive procedures, but they may also receive adequate infection control measures, such as hand hygiene, isolation, sterilization, or prophylaxis. The risk of infection in hospitalized clients depends on their diagnosis, treatment, and compliance.
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