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 ["A","B","C"]
Explanation
Choice A rationale
Bradycardia (slow heart rate) is one of the key components of Cushing's triad, which indicates increased intracranial pressure and impending herniation.
Choice B rationale
Bradypnea (slow respiratory rate) is another manifestation of Cushing's triad and reflects brainstem compression.
Choice C rationale
Hypertension (high blood pressure) is the third component of Cushing's triad, resulting from the body's attempt to maintain cerebral perfusion.
Choice D rationale
Tachycardia (rapid heart rate) is not a sign of Cushing's triad and is not associated with increased intracranial pressure.
Correct Answer is B
Explanation
Choice A rationale
Lordosis is an exaggerated inward curvature of the lumbar spine. It is commonly seen in pregnant women, individuals with obesity, or those with weak abdominal muscles. Lordosis is not characterized by an increased thoracic curvature.
Choice B rationale
Kyphosis is an exaggerated outward curvature of the thoracic spine, often resulting in a hunched or rounded back. It is commonly seen in older adults due to osteoporosis, degenerative disc disease, or poor posture. Kyphosis is the correct diagnosis for increased thoracic curvature.
Choice C rationale
Scoliosis is a lateral curvature of the spine, often resembling an "S" or "C" shape when viewed from behind. It can occur in any part of the spine but does not specifically describe an increased thoracic curvature.
Choice D rationale
Epiphyses refer to the growth plates at the ends of long bones in children and adolescents. They are not related to spinal curvature or any spinal disorder. .
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