A nurse is reviewing documentation describing a client's wound of right foot and heel. Which of the noted assessments indicate to the nurse that there is a problem with wound healing? (Select All That Apply)

Slough noted at the center of the wound

Maceration present at the base of the heel

No indications of undermining present

Absence of biofilm after mechanical debridement

Presentation of epithelialization identified at the peri-wound

Answer and Explanation

Correct Answer : A,B

A. Slough noted at the center of the wound: Slough consists of non-viable cellular debris and fibrin that provides a medium for bacterial growth and physically blocks the formation of new granulation tissue. Its presence indicates that the wound is stuck in the inflammatory phase and cannot progress to proliferation. It requires debridement to resume healing.

B. Maceration present at the base of the heel: Maceration occurs when the skin is exposed to excessive moisture for prolonged periods, causing it to become soft, white, and fragile. This compromises the integrity of the periwound skin and makes it susceptible to further breakdown or infection. It indicates poor management of wound exudate or moisture.

C. No indications of undermining present: Undermining is a negative finding where tissue destruction occurs underneath the intact skin at the wound margins. The "absence" of undermining is a positive sign that the wound is not tunneling or expanding deeper into the surrounding structures. It reflects a more stable and localized wound bed.

D. Absence of biofilm after mechanical debridement: Biofilms are complex communities of bacteria that are highly resistant to antibiotics and host immune responses. Removing them via debridement is a positive therapeutic outcome that allows the body's natural healing processes to take over. The absence of biofilm indicates a cleaner, more receptive wound bed.

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Correct Answer is D

Explanation

A. "The patch will work quickly and effectively to manage your pain.": Transdermal patches have a slow onset of action, often taking 12 to 24 hours to reach therapeutic steady-state levels. Promising a "quick" result is medically inaccurate and mismanages the client's expectations for relief. Patches are designed for long-term maintenance rather than rapid acute analgesia.

B. "The patch will give you a longer duration of pain relief especially during sleep.": While true that patches provide long-acting relief, this statement does not address the client's primary concern about adequacy or previous dissatisfaction with sedation. It fails to explain the pharmacokinetic advantage of consistent dosing over intermittent oral boluses. It provides incomplete education regarding the transition.

C. "The patch has creams and oils imbedded in it to prevent friction and shearing which can lead to skin breakdown.": This is a physiological falsehood regarding the construction of transdermal delivery systems. Patches contain a drug reservoir and an adhesive, but they are not designed as skin-protective barriers against mechanical shearing. Their purpose is systemic drug delivery, not localized dermatological protection.

D. "The patch will maintain consistent levels of the drug in your blood. We may be able to supplement with another pain medication until pain control is reached.": Continuous delivery avoids the "peaks" and "troughs" associated with oral meds, which often cause excessive sedation at peak and pain at trough. Informing the client about supplemental "breakthrough" medication provides a safety net during the slow onset period of the transdermal system.

A. The client usually starts the day at 0730. B. The client exercises before going to bed to "feel more tired." C. "If I am hungry after dinner, peanut butter on crackers is a typical snack for me." D. The client drinks sparkling water infused with fruit juice throughout the afternoon and evening to avoid caffeine.

Correct Answer is B

Explanation

A. The client usually starts the day at 0730: Maintaining a consistent wake-up time is a core principle of effective sleep hygiene. This practice helps regulate the circadian rhythm and promotes easier sleep onset the following night. It does not warrant further clinical discussion or corrective intervention by the nurse.

B. The client exercises before going to bed to "feel more tired": Vigorous physical activity within 2 to 3 hours of bedtime increases core body temperature and stimulates cortisol release. This physiological arousal interferes with the natural transition into sleep. Exercise should be scheduled earlier in the day to facilitate proper nocturnal cooling.

C. "If I am hungry after dinner, peanut butter on crackers is a typical snack for me": A light snack containing complex carbohydrates and protein can promote sleep by facilitating tryptophan entry into the brain. It prevents hunger-induced awakenings without causing significant gastrointestinal distress. This habit is generally supportive of healthy sleep patterns and needs no change.

D. The client drinks sparkling water infused with fruit juice throughout the afternoon and evening to avoid caffeine: Eliminating caffeine in the latter half of the day reduces the risk of chemical sleep interference. Since the beverages are caffeine-free, they do not act as stimulants. This choice reflects a positive adjustment to improve sleep quality and requires no intervention.

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A nurse is reviewing documentation describing a client's wound of right foot and heel. Which of the noted assessments indicate to the nurse that there is a problem with wound healing? (Select All That Apply)

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Correct Answer is D

Explanation

An adult client is discussing experiencing occasional episodes of insomnia. In assessing the client's approach to sleep, which client statement should the nurse discuss further with the client?

Correct Answer is B

Explanation

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