A nurse is developing a plan of care for a client who has a stage 3 pressure ulcer. Which of the following interventions should the nurse include in the plan?
Apply a heat lamp twice a day.
Reposition the client at least every 2 hours.
Massage reddened areas with dressing changes.
Clean the wound with hydrogen peroxide solution.
The Correct Answer is B
Choice A reason:
Applying a heat lamp twice a day is not recommended for treating stage 3 pressure ulcers. Heat lamps can cause burns and further damage to the already compromised skin. The primary goal in treating pressure ulcers is to reduce pressure, keep the area clean, and promote healing. Heat lamps do not contribute to these goals and can potentially worsen the condition.
Choice B reason:
Repositioning the client at least every 2 hours is a crucial intervention for managing stage 3 pressure ulcers. Frequent repositioning helps to alleviate pressure on the affected area, improving blood flow and preventing further tissue damage. This practice is essential in preventing the progression of pressure ulcers and promoting healing. It is one of the most effective strategies in pressure ulcer management.
Choice C reason:
Massaging reddened areas with dressing changes is not advisable. Massaging can cause additional trauma to the skin and underlying tissues, potentially worsening the ulcer. Instead, gentle handling and appropriate wound care techniques should be used to avoid further damage. Massaging can also disrupt the healing process and increase the risk of infection.
Choice D reason:
Cleaning the wound with hydrogen peroxide solution is not recommended for stage 3 pressure ulcers. Hydrogen peroxide can damage healthy tissue and delay the healing process. It is better to use saline or other wound cleaning solutions that are gentle and effective in removing debris without harming the tissue. Proper wound cleaning is essential to prevent infection and promote healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: Increasing age is a non-modifiable risk factor for cardiovascular disease. As people age, their risk of developing cardiovascular conditions naturally increases due to changes in the heart and blood vessels. However, age cannot be altered or controlled, making it a non-modifiable factor.
Choice B reason: Cigarette smoking is a significant modifiable risk factor for cardiovascular disease. Smoking damages the lining of the arteries, leading to atherosclerosis (narrowing and hardening of the arteries), which can result in heart attacks and strokes. Quitting smoking can significantly reduce the risk of cardiovascular disease, making it a key focus in prevention programs.
Choice C reason: Family history of cardiac disease is another non-modifiable risk factor. Genetics play a crucial role in the predisposition to cardiovascular diseases. If a close family member has had heart disease, the risk is higher. While this factor cannot be changed, awareness can lead to more proactive management of other modifiable risks.
Choice D reason: Diagnosis of diabetes mellitus is a complex risk factor. While having diabetes itself is not modifiable, the management of diabetes through lifestyle changes, medication, and monitoring can significantly reduce the risk of cardiovascular complications. Proper control of blood glucose levels, diet, and exercise are crucial in mitigating this risk.
Correct Answer is {"A":{"answers":"A,C"},"B":{"answers":"A,B,C"},"C":{"answers":"A,B,C"},"D":{"answers":"A,C"},"E":{"answers":"A"}}
Explanation
Joint Pain
Sickle Cell Disease: Joint pain is a common symptom of sickle cell disease due to vaso-occlusive crises, where sickle- shaped red blood cells block blood flow to the joints, causing pain and inflammation. These episodes can be severe and recurrent, leading to chronic pain and joint damage over time.
Leukemia: Joint pain can also be a symptom of leukemia, particularly in children. This occurs because leukemia cells can infiltrate the bone marrow, causing bone and joint pain. The pain is often due to the expansion of the marrow cavity by the leukemic cells.
Heart Rate at 1000
Sickle Cell Disease: An increased heart rate (tachycardia) can occur in sickle cell disease due to anemia. The body compensates for the reduced oxygen-carrying capacity of the blood by increasing the heart rate.
Iron Deficiency Anemia: Tachycardia is also a common symptom of iron deficiency anemia. The heart works harder to pump more blood to deliver adequate oxygen to tissues, resulting in an increased heart rate.
Leukemia: In leukemia, anemia can develop due to the replacement of normal bone marrow cells with leukemic cells, leading to a reduced number of red blood cells and subsequent tachycardia as the body attempts to compensate.
Respiratory Status
Sickle Cell Disease: Dyspnea (difficulty breathing) and labored breathing can occur in sickle cell disease due to anemia and acute chest syndrome, a severe complication where sickle cells block blood flow in the lungs.
Iron Deficiency Anemia: Respiratory symptoms such as shortness of breath and labored breathing are common in iron deficiency anemia due to the reduced oxygen-carrying capacity of the blood.
Leukemia: Leukemia can cause respiratory symptoms due to anemia and the infiltration of leukemic cells into the lungs, leading to reduced oxygenation and labored breathing.
Jaundice
Sickle Cell Disease: Jaundice is a common symptom of sickle cell disease due to the increased breakdown of red blood cells (hemolysis), leading to elevated bilirubin levels.
Leukemia: Jaundice can also occur in leukemia if the liver is infiltrated by leukemic cells or if there is significant hemolysis.
Ankle Ulcer
Sickle Cell Disease: Ankle ulcers are a common complication of sickle cell disease. They result from poor blood flow and oxygen delivery to the skin, leading to chronic, non-healing ulcers.
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