The nurse documenting an acute open wound should include which characteristics? Select all that apply.

Wound size.

Wound bed.

Periwound skin.

Pattern of eruption.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

Documenting wound size includes measuring the length, width, and depth of the wound to track the healing process and plan appropriate interventions.

Choice B rationale

The wound bed should be assessed for tissue type (granulation, slough, or eschar), color, and the presence of any exudate or infection.

Choice C rationale

The periwound skin is the area around the wound which should be assessed for color, temperature, swelling, and signs of maceration or excoriation.

Choice D rationale

Pattern of eruption is more relevant to dermatological conditions such as rashes or lesions, and not a primary focus for documenting acute open wounds.

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Correct Answer is A

Explanation

Choice A rationale

Percutaneous absorption of topical corticosteroids increases systemic exposure, potentially causing side effects like adrenal suppression, hyperglycemia, and Cushing's syndrome. This is particularly significant when potent corticosteroids are applied to large body areas or under occlusive dressings, enhancing absorption and systemic effects.

Choice B rationale

Topical corticosteroids primarily induce vasoconstriction, not vasodilation, reducing inflammation and redness in skin conditions. Incorrect understanding of their vasodilatory effects may misguide nursing interventions, making it less relevant to the injury risk in atopic dermatitis treatments.

Choice C rationale

Topical corticosteroids have minimal systemic interactions compared to oral or intravenous forms, making drug interaction concerns less pertinent. The risk of significant drug interactions is low unless the medication is systemically absorbed in substantial amounts.

Choice D rationale

Application to face, neck, and intertriginous sites increases the risk of local side effects like skin atrophy, but is not a primary concern for systemic injury risk. These areas have thinner skin, enhancing absorption and risk of local adverse effects, but not necessarily systemic harm.

A. Coping strategies. B. Wrist circumference. C. Clinical examination findings. D. BMI. E. Dietary data.

Correct Answer is ["C","D","E"]

Explanation

Choice A rationale

Coping strategies are relevant to overall health and well-being, but they are not directly related to nutritional assessment. Nutritional assessments focus on physical and dietary data rather than psychological coping mechanisms.

Choice B rationale

Wrist circumference can be used as an anthropometric measure of body frame size, but it is not a standard parameter in a comprehensive nutritional assessment. More common measurements include height, weight, and BMI.

Choice C rationale

Clinical examination findings are critical in nutritional assessments to identify physical signs of malnutrition, such as muscle wasting, edema, or skin changes. These observations help assess the client’s nutritional status and needs.

Choice D rationale

BMI (Body Mass Index) is a widely used indicator of body fat based on height and weight. It helps classify individuals into categories like underweight, normal weight, overweight, or obese, providing insight into nutritional health.

Choice E rationale

Dietary data, including food intake, preferences, and restrictions, are essential components of a nutritional assessment. Understanding a client's dietary habits allows the nurse to identify nutritional deficiencies or excesses and plan appropriate interventions

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The nurse documenting an acute open wound should include which characteristics? Select all that apply.

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Naxlex Comprehensive Predictor Exams

Correct Answer is A

Explanation

A newly admitted client has gained weight steadily over the past 2 years and the nurse recognizes the need for a nutritional assessment. What assessment parameters should the nurse include? Select all that apply.

Correct Answer is ["C","D","E"]

Explanation

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