The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply.
Palpate the client's skin for moisture, temperature, and texture.
Ask the client whether the wound bed or surrounding skin itches.
Measure and assess the client's wound bed, size, edges, and margins.
Evaluate the client's level of pain, using a numeric value pain scale.
Review the client's prothrombin time test and international normalized ratio.
Correct Answer : A,C,D
Choice A rationale
Palpating the client's skin for moisture, temperature, and texture is essential in wound management. This allows the nurse to assess for signs of infection or inflammation, which can affect the wound healing process. Moisture can indicate excessive drainage or sweating that might macerate the skin, while changes in temperature and texture can signify infection or poor blood flow.
Choice B rationale
While asking the client whether the wound bed or surrounding skin itches may provide some information about the client's comfort, it is not a primary intervention for wound management. Itching can be a sign of healing or irritation, but it does not provide direct information on the wound's condition.
Choice C rationale
Measuring and assessing the wound bed, size, edges, and margins are critical steps in wound management. This helps to determine the progression of healing, the presence of necrotic tissue, and any changes in the wound over time. Accurate measurement and documentation are essential for developing an appropriate care plan.
Choice D rationale
Evaluating the client's level of pain using a numeric value pain scale is important in wound management. Pain can indicate underlying issues such as infection, poor perfusion, or neuropathy. Assessing pain helps guide interventions to provide comfort and address any complications that may arise.
Choice E rationale
Reviewing the client's prothrombin time test and international normalized ratio is not a standard intervention for wound management. These tests are more relevant to assessing the client's coagulation status, which may be important for surgical or anticoagulant therapy but not directly for wound care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Ligaments connect bones and stabilize joints. Age-related changes in ligaments result in decreased elasticity, leading to joint stiffness but not directly causing loss of height.
Choice B rationale
Bones undergo resorption and may lose density with age, leading to osteoporosis. While this contributes to height loss, it is not typically associated with diminished range of motion or flexibility as primary symptoms.
Choice C rationale
Muscles lose mass and strength with aging, a condition known as sarcopenia. This affects flexibility and range of motion but does not lead directly to height loss.
Choice D rationale
Joints are affected by age-related changes such as cartilage wear and synovial fluid reduction, leading to stiffness, loss of flexibility, diminished range of motion, and height loss due to spinal disc compression and vertebral changes.
Correct Answer is D
Explanation
Choice A rationale
Cerebrospinal fluid (CSF) does not produce cerebral neurotransmitters. Neurotransmitters are produced by neurons in the brain and nervous system.
Choice B rationale
CSF provides a protective barrier to some extent, but its primary function is not to act as a barrier to bacteria. The blood-brain barrier primarily serves this function.
Choice C rationale
CSF helps maintain a stable environment in the central nervous system but is not primarily an insulator for maintaining constant temperature. Its thermal properties are secondary.
Choice D rationale
The primary function of CSF is to cushion and protect the brain and spinal cord from mechanical injury. It also helps maintain the brain's buoyancy and provides a stable environment for the central nervous system.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.
