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Exhibits

Complete the diagram below by dragging from the list of the choices to specify what condition the client is most likely experiencing, 2 actions to take and 2 parameters to monitor.

Answer and Explanation

The Correct Answer is []

Based on the nurse notes and clinical findings, here's how the diagram should be completed along with the rationale for each choice:

Potential Condition: Pressure Injury

The client presents with non-blanchable redness and partial thickness tissue loss on the left heel, which is consistent with a Stage II pressure injury. This is common in immobile patients, especially those who are wheelchair-bound and have comorbidities like diabetes and poor nutritional status (low albumin).

Actions to Take

  1. Position the client to remove pressure off of bony extremity: Offloading pressure from the affected area is critical to prevent worsening of the pressure injury and promote healing. Repositioning every 2 hours is standard care.
  2. Call the Healthcare provider: The elevated WBC count (27,000) suggests a possible infection. Combined with tissue breakdown, this could indicate cellulitis or early sepsis. Prompt medical evaluation is necessary.

 

Parameters to Monitor

  1. WBC count: A high WBC count may indicate infection or inflammation. Monitoring trends helps assess response to treatment and progression of infection.
  2. Pain: Pressure injuries can be painful, especially as tissue damage progresses. Pain assessment guides comfort measures and may indicate worsening of the condition.

Rationale for incorrect choices

  • Massage any reddened areas: This is contraindicated in pressure injuries as it can worsen tissue damage.
  • Administer narcotics immediately: Pain management is important, but narcotics should be used judiciously and only after proper assessment.
  • Atelectasis, Blood clot, Pneumonia: These are not supported by the current findings.
  • Blood Glucose, Oxygen saturation: While relevant to overall care, they are not the most critical parameters for this condition.


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Related Questions

Correct Answer is C

Explanation

A. Stomach: The stomach aids digestion and can contribute to absorption, but it is not the primary organ for systemic drug metabolism.

B. Heart: The heart circulates blood but is not a major site of drug metabolism.

C. Liver: The liver is the principal organ for drug metabolism (hepatic enzymatic biotransformation and the first-pass effect), making it central to how most medications are processed.

D. Pancreas: The pancreas produces digestive enzymes and hormones like insulin, but it is not the main organ responsible for medication metabolism.

Correct Answer is A

Explanation

A. Sit beside the client and ask how his care team can best support his spiritual needs: Sitting with the client, showing presence, and asking an open question honors the client's expressed spirituality and allows the nurse to assess and facilitate appropriate support (e.g., chaplain, family involvement, reading scripture).

B. Avoid eye contact and call a chaplain for the client to talk to about spiritual matters: Calling a chaplain can be appropriate, but avoiding eye contact and withdrawing from the moment neglects immediate emotional support the nurse can provide.

C. Place a sign on the door to allow the client some quiet time in the mornings: Providing privacy may be useful, but it does not respond to the client’s expressed emotion or request in the moment.

D. Tell the client that his spirituality is impressive: Praising or judging the client’s spirituality shifts focus to the nurse’s view rather than supporting the client’s needs; a reflective, empathetic response is more therapeutic.

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