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 B

Explanation

Choice A rationale

Lordosis is an exaggerated inward curvature of the lumbar spine. It is commonly seen in pregnant women, individuals with obesity, or those with weak abdominal muscles. Lordosis is not characterized by an increased thoracic curvature.

Choice B rationale

Kyphosis is an exaggerated outward curvature of the thoracic spine, often resulting in a hunched or rounded back. It is commonly seen in older adults due to osteoporosis, degenerative disc disease, or poor posture. Kyphosis is the correct diagnosis for increased thoracic curvature.

Choice C rationale

Scoliosis is a lateral curvature of the spine, often resembling an "S" or "C" shape when viewed from behind. It can occur in any part of the spine but does not specifically describe an increased thoracic curvature.

Choice D rationale

Epiphyses refer to the growth plates at the ends of long bones in children and adolescents. They are not related to spinal curvature or any spinal disorder. .

A. Dysfunction in the cerebrum. B. Dysfunction in the brain stem. C. Dysfunction in the spinal column. D. Dysfunction in the motor cortex.

Correct Answer is B

Explanation

Choice A rationale

Dysfunction in the cerebrum would likely result in different types of posturing, such as decorticate posturing, rather than decerebrate. The cerebrum is involved in controlling voluntary motor functions and damage here typically does not lead to decerebrate posturing.

Choice B rationale

Dysfunction in the brain stem results in decerebrate posturing, characterized by rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. The brain stem is crucial for controlling basic life functions and its impairment leads to severe motor response issues.

Choice C rationale

Dysfunction in the spinal column typically does not lead to decerebrate posturing but may lead to different types of paralysis or movement issues depending on the location and severity of the damage.

Choice D rationale

Dysfunction in the motor cortex usually leads to abnormalities in voluntary movement, muscle tone, and coordination rather than decerebrate posturing which is more linked to brain stem issues.

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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

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Correct Answer is B

Explanation

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Correct Answer is B

Explanation

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