A nurse is caring for a client who is scheduled for surgery.

Exhibits

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

Mini Nutritional Assessment screening tool score

History of hyperlipidemia

History of malnutrition

History of diabetes mellitus

Cholesterol level

Prealbumin level

Answer and Explanation

Correct Answer : C,D,F

A.   Mini Nutritional Assessment screening tool score: While it indicates the risk of malnutrition, it's not directly linked to delayed wound healing.
B.   History of hyperlipidemia: Hyperlipidemia itself doesn't directly affect wound healing.
C.   History of malnutrition: Malnutrition significantly hampers the body's ability to heal wounds effectively.
D.   History of diabetes mellitus: Diabetes can impair wound healing due to poor blood sugar control affecting the immune system and circulation.
E.   Cholesterol level: Elevated cholesterol, while relevant to overall health, is not directly linked to delayed wound healing.
F.   Prealbumin level: Prealbumin is a marker for nutritional status; lower levels indicate inadequate protein intake and can contribute to delayed wound healing.

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Correct Answer is A

Explanation

- Rationale for A: Rolling the client as one unit helps maintain spinal alignment and prevents further injury. It ensures that no additional strain is placed on the injured area, which could exacerbate pain or cause further damage. This method distributes the client's weight evenly and avoids twisting movements that could be harmful.

- Rationale for B: While flexing the client's knees may be part of the process to prepare for repositioning, it is not the most critical action to take. Flexing the knees alone does not ensure the safety of the client's lower back and could potentially lead to discomfort or injury if not done in conjunction with other measures.

- Rationale for C: Placing the client's arms at their sides is not advisable as it does not provide any support or stability during the repositioning process. Arms should be positioned in a way that they do not bear weight or interfere with the movement, ensuring the client's comfort and safety.

- Rationale for D: While placing the client on the side of the bed nearest the direction they will be turned may seem practical, it is not the primary action to ensure the client's safety. This position does not address the need for maintaining proper spinal alignment or the smooth, controlled movement required to protect the lower back injury.

A. Metabolic syndrome B. Participation in competitive sports C. Family history of alcohol use disorder D. Hypotension

Correct Answer is A

Explanation

A. Metabolic syndrome is a cluster of conditions that include high blood pressure, high blood sugar, excess body fat around the waist, and abnormal cholesterol or triglyceride levels, all of which increase the risk of cardiovascular disease.
B. Participation in competitive sports might enhance cardiovascular fitness and decrease the risk of cardiovascular diseases.
C. While alcohol use disorder can have health implications, it's not a direct risk factor for cardiovascular disease.
D. Hypotension (low blood pressure) is generally not considered a significant risk factor for cardiovascular disease, unlike hypertension (high blood pressure).

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A nurse is caring for a client who is scheduled for surgery. Exhibits The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.

Nursing Test Bank

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A nurse is caring for a client who is scheduled for surgery.

Exhibits

The nurse is reviewing the client's medical record. Which of the following findings places the client at risk for delayed wound healing? Select all that apply.