When performing dressing changes in an older client, what should the nurse assess for?
Signs of infection
Skin color changes
Decreased pain levels
Changes in blood pressure
The Correct Answer is A
A. Signs of infection: Older adults may have compromised immune systems and are more susceptible to infections. During dressing changes, the nurse should assess for signs of infection such as increased redness, swelling, warmth, drainage, or foul odor, which could indicate an infection at the wound site.
B. Skin color changes: While changes in skin color can be indicative of various skin conditions or circulation problems, assessing for signs of infection is more pertinent during dressing changes to prevent and manage complications.
C. Decreased pain levels: Older adults may have altered pain perception due to age-related changes or comorbidities. However, assessing for signs of infection takes priority during dressing changes to ensure timely intervention if infection is present.
D. Changes in blood pressure: Changes in blood pressure may be relevant in certain clinical contexts but are not specifically related to performing dressing changes in older clients.
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Related Questions
Correct Answer is B
Explanation
A. A 49-year-old who works in food services: While individuals working in food services may be at risk of exposure to influenza, they are not in the highest priority group. Age and underlying health conditions are typically prioritized over occupational risk factors.
B. An 88-year-old who lives in an apartment for senior citizens: Older adults, especially those living in congregate settings like senior citizen apartments, are at higher risk of complications from influenza. Therefore, the 88-year-old should have the highest priority to receive the vaccine.
C. A 26-year-old with three young children: While having young children may increase the risk of exposure to influenza, younger adults without underlying health conditions are generally at lower risk of severe complications compared to older adults.
D. A 15-year-old who plays ice hockey: While participation in activities like ice hockey may increase the risk of exposure to respiratory infections, age and health status are more significant factors in determining priority for influenza vaccination.
Correct Answer is B
Explanation
A. Normal white blood cell count: In wound sepsis, the white blood cell count is typically elevated as part of the body's immune response to infection, not normal.
B. Fever and chills: Fever (hyperthermia) and chills are common signs of systemic infection, including wound sepsis. They indicate an inflammatory response and activation of the body's defense mechanisms.
C. Decreased pain at the wound site: Increased pain at the wound site is more commonly associated with wound infection, not decreased pain.
D. Redness and swelling: Redness (erythema) and swelling (edema) are local signs of inflammation and can be present in infected wounds, but they are not specific to wound sepsis and may occur in non-infected wounds as well.
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