A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority?

Promote positive nitrogen balance.

Facilitate neutral nitrogen balance.

Reduce dependent nitrogen balance.

Maintain negative nitrogen balance.

Answer and Explanation

The Correct Answer is A

Choice A reason: Promoting positive nitrogen balance is critical for postsurgical wound healing, as it indicates adequate protein intake for tissue repair. Surgery increases metabolic demand, depleting amino acids needed for collagen synthesis and immune function. Positive balance supports fibroblast activity and wound tensile strength, reducing infection risk and promoting recovery in the healing process.

Choice B reason: Neutral nitrogen balance maintains protein homeostasis but is insufficient for postsurgical patients, who require excess protein for tissue repair. Surgery induces catabolism, increasing nitrogen loss via urine. Neutral balance does not provide the surplus amino acids needed for collagen formation and immune response, slowing wound healing and increasing complication risks.

Choice C reason: Reducing dependent nitrogen balance is not a recognized medical goal. Nitrogen balance reflects protein metabolism, critical for wound healing. Postsurgical patients need positive balance to supply amino acids for tissue regeneration. This option is vague and irrelevant, as it does not address the physiological need for increased protein synthesis post-surgery.

Choice D reason: Maintaining negative nitrogen balance indicates protein catabolism exceeding synthesis, detrimental to wound healing. Postsurgical stress increases cortisol, promoting protein breakdown. Negative balance impairs collagen production and immune function, delaying wound closure and increasing infection risk. Positive nitrogen balance is essential to support tissue repair and recovery in surgical patients.

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Correct Answer is A

Explanation

Choice A reason: The nursing process (assessment, diagnosis, planning, implementation, evaluation) guides the creation of a client’s care plan, providing a systematic, evidence-based framework. It ensures individualized, goal-oriented care, addressing client needs comprehensively, and is the cornerstone of clinical decision-making, per nursing practice standards.

Choice B reason: Nursing’s Social Policy Statement defines the profession’s role and societal obligations, not a practical guide for care planning. It provides a philosophical framework, not actionable steps like the nursing process, making it irrelevant for creating specific client care plans, per professional guidelines.

Choice C reason: The Nurse Practice Act regulates licensure and scope of practice, not care plan development. It ensures legal compliance but does not provide a clinical framework like the nursing process, which directly structures patient care, making this incorrect for care planning, per regulatory standards.

Choice D reason: ANA Standards of Nursing Practice outline professional expectations but are not a step-by-step guide like the nursing process. They support quality care but lack the specific, systematic approach needed for creating individualized care plans, per nursing practice and clinical guideline frameworks.

A. Respecting the desire to have the uncle make choices on the client’s behalf B. Revisiting the decision when the uncle is not present at the bedside C. Educating the client about the right to autonomy D. Holding a family meeting and encouraging the client to speak on their own behalf

Correct Answer is A

Explanation

Choice A reason: Respecting the client’s cultural preference to defer decisions to their uncle upholds autonomy, a principle of self-determination. In some cultures, family patriarchs guide health decisions, reflecting collective values. This respects the client’s psychological and social framework, ensuring decisions align with their beliefs, reducing stress and supporting informed consent within their cultural context.

Choice B reason: Revisiting decisions without the uncle disregards the client’s cultural values, undermining autonomy. Cultural norms may prioritize family decision-making, reducing individual stress by aligning with social structures. Ignoring this preference risks psychological distress and distrust, as it dismisses the client’s chosen decision-making process, which is integral to their identity and coping mechanism.

Choice C reason: Educating about autonomy assumes the client’s preference is uninformed, potentially disrespecting their cultural values. In collectivist cultures, deferring to family supports psychological well-being, reducing decision-making stress. Imposing individual autonomy may increase anxiety, as it conflicts with the client’s social framework, undermining trust and effective nurse-client communication.

Choice D reason: Encouraging the client to speak in a family meeting may pressure them against their cultural preference, compromising autonomy. Deferring to a patriarch aligns with collectivist values, reducing psychological stress. Forcing individual expression risks cultural insensitivity, increasing anxiety and disrupting trust, as it conflicts with the client’s chosen decision-making process.

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A nurse is caring for a patient with a postsurgical wound. When planning care, which goal will be the priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The client's plan of care is created by the nurse using which guideline for nursing practice?

Correct Answer is A

Explanation

A client with a diagnosis of colorectal cancer has been presented with treatment options but wishes to defer any decisions to an uncle, who acts in the role of a family patriarch within the client’s culture. The client’s right to self-determination is best protected by:

Correct Answer is A

Explanation

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