A client's orders include a wound dressing using an autolytic debriding agent. The nurse providing discharge instructions to the client should include which statement?

Keep the dressing very wet at all times.

Do not use a dressing 6 hours/day.

Cleanse the wound with Dakin's solution.

The wound may have a foul odor.

Answer and Explanation

The Correct Answer is D

Choice A rationale

Keeping the dressing very wet at all times is not advisable with autolytic debriding agents. Excess moisture can cause maceration of the surrounding skin and increase the risk of infection. The dressing should maintain an optimal level of moisture to promote autolysis without causing harm.

Choice B rationale

Not using a dressing for 6 hours/day is incorrect advice. Continuous application of the dressing is essential for the autolytic process. Removing the dressing for extended periods disrupts the environment needed for autolysis, delaying wound healing.

Choice C rationale

Cleansing the wound with Dakin's solution is not recommended with autolytic debridement. Dakin's solution is a chemical debriding agent, and its use can interfere with the natural autolytic process. It is better to use saline or appropriate cleansers as directed.

Choice D rationale

The wound may have a foul odor due to the autolytic debridement process. As dead tissue is broken down, it can produce a distinct odor. Educating the client about this expected outcome helps them understand that it is a normal part of the healing process and not necessarily a sign of infection.

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Correct Answer is A

Explanation

Choice A rationale

Administering systemic antibiotics is essential to treat the underlying bacterial infection causing severe impetigo. This intervention helps reduce infection spread and promotes healing.

Choice B rationale

Placing mitts on the client's hands may prevent scratching, which can worsen impetigo, but it is not the primary treatment for the infection itself. Antibiotic therapy is more crucial.

Choice C rationale

Continuing antibiotics for 21 days is not a standard duration for impetigo treatment. The treatment duration typically ranges from 7 to 10 days, depending on the severity and response to treatment.

Choice D rationale

Topical antibiotics are used for mild cases of impetigo. For severe impetigo, systemic antibiotics are more appropriate and effective in managing the infection.

A. Ataxic. B. Dystrophic. C. Steppage. D. Helicopod. E. Helicopod.

Correct Answer is D

Explanation

Choice A rationale

Ataxic gait is characterized by uncoordinated movement, wide-based steps, and irregular distances between steps, often seen in cerebellar dysfunctions.

Choice B rationale

Dystrophic gait is associated with muscle weakness, often seen in muscular dystrophies, where there is difficulty in walking, a waddle-like walk, and frequent falls.

Choice C rationale

Steppage gait is associated with foot drop, where the individual lifts their knees higher than usual to avoid dragging their toes, often seen in peripheral neuropathies.

Choice D rationale

Helicopod gait involves the feet making a half-circle with each step and is often seen in individuals with certain neurologic disorders, such as hemiplegia or certain types of ataxia.

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A client's orders include a wound dressing using an autolytic debriding agent. The nurse providing discharge instructions to the client should include which statement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

When caring for a client with severe impetigo, the nurse should include which intervention in the care plan?

Correct Answer is A

Explanation

A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?

Correct Answer is D

Explanation

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