Client has a history of malnutrition, hyperlipidemia, and diabetes mellitus.
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.
Cholestrol level
Prealbumin level
History of malnutrition
History of diabetes mellitus
History of hyperlipidemia)
Correct Answer : B,C,D
A. Cholesterol level:
While hyperlipidemia (elevated cholesterol levels) is associated with cardiovascular disease, it is not a direct factor affecting wound healing. Cholesterol levels primarily impact vascular health and are not directly related to the cellular and tissue processes involved in wound repair.
B. Prealbumin level:
Prealbumin is a protein that reflects recent dietary intake and nutritional status. Low prealbumin levels can indicate malnutrition, which is associated with delayed wound healing. Adequate protein intake is crucial for tissue repair and wound healing.
C. History of malnutrition:
Malnutrition is a significant risk factor for delayed wound healing. Adequate nutrition is essential for the body to carry out the processes involved in wound healing, including cell proliferation, collagen synthesis, and immune function.
D. History of diabetes mellitus:
Diabetes mellitus can impair wound healing due to factors such as reduced blood flow, impaired immune response, and neuropathy. Elevated blood sugar levels in diabetes can interfere with the normal healing processes, leading to delayed wound healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Elevate full-length side rails on both sides of the client's bed:
While side rails are used to prevent falls, full-length side rails can pose a risk to the client. They may give a false sense of security, and there's a risk of entrapment or injury if the client tries to climb over them. The use of side rails requires careful assessment and consideration of the individual client's needs.
B. Place the bedside table 0.9 m (3 feet) away from the bed:
Placing the bedside table 0.9 m (3 feet) away from the bed may not directly address the risk of falls. The focus should be on making essential items easily accessible to the client to minimize the need for them to get out of bed, especially during the night. Placing items within the client's reach is a more practical approach.
C. Keep the client's room temperature at 18°C (64.4°F):
While maintaining a comfortable room temperature is important for the client's overall well-being, it is not a direct preventive measure for falls. Falls are more likely to be prevented by addressing environmental factors, ensuring clear pathways, and providing adequate lighting.
D. Provide the client with a night light:
This is the appropriate action. A night light helps improve visibility during nighttime, reducing the risk of falls. It allows the client to see their surroundings better and navigate the room safely if they need to get out of bed.
Correct Answer is A
Explanation
A. "I will walk three times per week."
Weight-bearing exercises like walking help strengthen bones and reduce the risk of osteoporosis. Regular physical activity is a key component in maintaining bone health.
B. "I will take 250 milligrams of calcium once per day."
This amount of calcium is insufficient. The recommended daily intake for older adults is typically around 1,000 to 1,200 milligrams of calcium per day, divided into doses for better absorption.
C. "I will decrease my intake of dairy products."
Dairy products are rich sources of calcium and are beneficial for bone health. Decreasing their intake would not be advisable for reducing the risk of osteoporosis.
D. "I will avoid exposure to the sun."
Sun exposure helps the body produce vitamin D, which is essential for calcium absorption and bone health. Avoiding sun exposure could lead to a deficiency in vitamin D, increasing the risk of osteoporosis.
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