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 ["B","C","D"]

Explanation

Choice A rationale

Tachycardia is not a symptom of Cushing's triad; it is often associated with other conditions such as stress or heart problems.

Choice B rationale

Bradypnea is a hallmark of Cushing's triad, indicating decreased respiratory rate due to increased intracranial pressure.

Choice C rationale

Hypertension is a key component of Cushing's triad, caused by increased intracranial pressure leading to elevated blood pressure.

Choice D rationale

Bradycardia, or a slower than normal heart rate, is a symptom of Cushing's triad, resulting from increased pressure in the brain affecting the heart rate.

Choice E rationale

Pupillary constriction is not typically associated with Cushing's triad; it is usually related to other neurological conditions.

A. Improve the school hygiene. B. Insist that everyone who is infested with lice follows the prescribed treatment. C. Wash clothing and vacuum furniture, bedding, and carpets. D. Perform hair inspection.

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

Explanation

Choice A rationale

Improving school hygiene is essential for overall health but is not a direct method for preventing and controlling an outbreak of pediculosis. Lice infestations require specific targeted actions to be effectively managed, such as treating those infested and cleaning their belongings.

Choice B rationale

Insisting that everyone who is infested with lice follows the prescribed treatment is crucial for controlling the outbreak. Effective treatment eradicates lice and prevents their spread to others. Consistency in following the prescribed regimen is essential for successful management.

Choice C rationale

Washing clothing and vacuuming furniture, bedding, and carpets are vital steps in controlling lice outbreaks. Lice can survive on these items, leading to reinfestation. Thorough cleaning removes lice and their eggs, helping to prevent the spread and recurrence of infestation.

Choice D rationale

Performing hair inspection helps identify individuals who are infested with lice. Early detection allows for prompt treatment, which is critical in preventing the spread of lice to others. Regular inspections are a proactive measure in managing and controlling outbreaks.

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

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse caring for a client with head trauma will be monitoring the client for Cushing's triad. What will the nurse recognize as the symptoms associated with Cushing's triad? Select all that apply.

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

Explanation

A nurse employed in a school suspects an outbreak of pediculosis. Which of the following nursing actions should be taken to prevent and control the outbreak?

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

Explanation

Which occurs when reflexes are hyperactive when the foot is abruptly dorsiflexed?

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