Exhibits

The nurse provides education about seizures to the client and asks the client to explain what he understands about his condition.

For each statement click to specify if the client demonstrates an understanding or no understanding. Each row must have one option selected.

A. A first voided morning specimen is often used for detecting conditions such as urinary tract infections (UTIs) or pregnancy because it is more concentrated and may provide a clearer result. However, for diagnosing urethritis specifically, a clean catch or midstream specimen is generally preferred to minimize contamination and better identify pathogens.
B. A clean catch urine specimen is the most appropriate method for diagnosing urethritis. This method reduces the risk of contamination from bacteria that may be present in the initial or final part of the urine stream, providing a more accurate representation of the urine coming directly from the bladder.
C. Collecting any specimen after drinking fluids is not a standardized method for diagnosing urethritis. While adequate fluid intake is generally important for urine production and can help dilute the urine, the quality and accuracy of the specimen are more reliably ensured through specific collection techniques such as a clean catch.
D. A 24-hour urine collection is used for assessing the overall function of the kidneys and measuring substances that vary in concentration throughout the day, such as proteins or electrolytes. It is not typically used for diagnosing urethritis, which is usually evaluated with a clean catch specimen for a more immediate assessment of infection or inflammation.

Potential Condition
Poor healing of stage 2 pressure injury
The stage 2 pressure injury on the right trochanter with minimal drainage and pain suggests poor healing, which is often due to a combination of factors including immobility, malnutrition, and other risk factors. The Braden Scale score reflects several high-risk areas that contribute to the poor healing of the pressure injury.
Actions to Take

1. Apply pressure reduction mattress to bed
A pressure reduction mattress helps alleviate pressure on vulnerable areas and can significantly reduce the risk of further injury and promote healing. It is a crucial intervention for managing pressure injuries and preventing new ones.
2. Request service of wound care nurse
Consulting a wound care nurse can provide specialized assessment and treatment for the pressure injury. This professional can recommend advanced wound care techniques and products to support optimal healing and address any complications.
Parameters to Monitor

1. Progression of wound
Monitoring the progression of the wound involves assessing changes in size, depth, and appearance of the pressure injury. This helps evaluate the effectiveness of interventions and the rate of healing.
2. Adherence to repositioning schedule

Regular repositioning is crucial to relieve pressure on vulnerable areas and prevent further injury. Ensuring that the client is repositioned according to the schedule helps prevent pressure ulcers from worsening and supports healing.
Incorrect conditions

Immobility: Although immobility is a factor in pressure injuries, the direct intervention would be to improve mobility, not necessarily apply to the current situation.
Dehydration: While dehydration can affect skin health and healing, the primary condition here is the poor healing of the pressure injury rather than dehydration itself.
Malnutrition: Malnutrition can impair wound healing, but the immediate action would be more related to wound care and pressure relief. Nutrition might be addressed separately through dietary interventions.