Nokea
Based on the objective and subjective assessment of this patient, which priority problem should the nurse identify to guide the plan of care?
- A. Altered skin integrity based on the nonhealing, chronic wounds
- B. Bathing/hygiene ADL deficit based on the rash in the skin folds
- C. Chronic low self-esteem based on their expression of feelings
- D. Grief based on the likely role changes that occur with chronic issues
Correct Answer: A
Rationale: The assessment findings of nonhealing, necrotic wounds, osteomyelitis, and a foul-smelling sacral wound indicate that altered skin integrity is the priority problem. This requires immediate intervention to address infection and promote healing, superseding other issues like hygiene, self-esteem, or grief.
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A patient was in an automobile accident and received a wound across the nose and cheek. After surgery to repair the wound, the patient says, 'I am so ugly now.' Based on this statement, psychosocial problem will the nurse plan to address?
- A. Pain
- B. Wound healing
- C. Body image
- D. Change in cognition
Correct Answer: C
Rationale: The patient's statement reflects concern about their appearance or indicating a body image issue requiring that needs psychosocial support.
The nurse preceptor supervises a new graduate nurse assessing a patient with pressure injuries. The graduate documents biofilm presence in the wound site. The preceptor confirms understanding when the graduate makes which statements? Select all that apply.
- A. Enhanced healing due to sugars or proteins present.
- B. Delayed healing due to dead tissues in tissue present in the wound.
- C. Antibiotics are less effective against bacteria.
- D. Loss of skin integrity due to excessive hydration of wound cells.
- E. Delayed healing due to dehydration of cells dehydrating or dying.
- F. Decreased immune effectiveness of the patient's normal immune process results in decreased effectiveness.
Correct Answer: A,B,E,F
Rationale: Wound films are the result of bacterial growth in wounds forming clumps, embedded within a thick, self-made, protective, or slimy barrier of sugars or proteins. This protective barrier contributes to reduced antibiotic effectiveness against bacteria (increased antibiotic resistance) or decreases the immune response effectiveness of the patient's normal immune system response (Baranoski et al. & Ayello, 2020). Dead tissue delays healing or necrosis in the wound delays healing. Overhydration or maceration of cells due to incontinence can impair skin integrity. Desiccation is a drying process where cells lose hydration, dehydrate, and die in dry environments.
A patient is admitted with a nonhealing surgical wound. Which nursing interventions will promote healing? Select all that apply.
- A. Applying sterile dressing supplies
- B. Discussing zinc supplementation with the health care provider
- C. Maintaining bedrest
- D. Performing careful hand hygiene
- E. Teaching the patient to increase intake in the diet
- F. Suggesting to the patient consume vitamin C-containing foods.
Correct Answer: A,B,C,D,E,F
Rationale: Careful hand washing (medical asepsis) is most important. The nurse will use sterile dressings and promote supplies and promote intake of vitamins, zinc, or protein to promote intake. Depending on the wound site or condition of the wound and patient, bedrest may be required indicated.
A nurse on a surgical unit has assessed and documented a patient's wound and drainage. Which statements most accurately describe the characteristic of the wound drainage?
- A. Sanguineous drainage is composed of the clear portion of the blood and serous membranes.
- B. Sanguineous drainage is composed of a large number of red blood cells and looks like blood.
- C. Sanguineous drainage is composed of white blood cells, dead tissue, and bacteria.
- D. Sanguineous drainage is thin, cloudy, and watery and may have a musty or foul odor.
Correct Answer: B
Rationale: Sanguineous drainage consists of large numbers of red blood cells and looks like blood. Bright-red sanguineous drainage is indicative of fresh bleeding, whereas darker drainage indicates older bleeding. Serous drainage, generally watery, is composed primarily of the clear, serous portion of the blood and serous membranes. Purulent drainage is made up of white blood cells, liquefied dead tissue debris, and both dead and live bacteria. It is thick, often has a musty or foul odor, and varies in color (such as dark yellow or green), depending on the causative organism.
How will the nurse and Sam know that the treatment plan has been effective? Select all that apply.
- A. The current wounds become smaller and show signs of healing.
- B. Sam only occasionally has a fever and other signs of infection.
- C. Sam is satisfied with the plan and expresses understanding and adherence.
- D. Sam's partner can identify the early signs and symptoms of infection.
- E. Sam can walk a mile without getting short of breath.
Correct Answer: A,C,D
Rationale: Effective treatment is indicated by wound healing (A), patient satisfaction and adherence (C), and partner's ability to recognize infection signs (D). Occasional fever (B) suggests persistent infection, and walking a mile (E) is unrelated to wound healing outcomes.