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Exhibits

The nurse reviews the client's data.

After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.

Apply a zinc based cream with brief changes

Apply powder to the perineum

Provide a donut shaped pillow to sit on

Use an antimicrobial soap to clean skin

Place a foam pad on the bed

Ensure the client slides up in bed on their own

Two person assist to move up in bed using slide sheet

Elevate the head of bed above 30 degrees

Request a physical therapy consult

Answer and Explanation

Correct Answer : A,E,G,I

A. Apply a zinc-based cream with brief changes. Zinc-based creams create a protective barrier against moisture and irritation from incontinence. This helps prevent skin breakdown by reducing the effects of prolonged exposure to urine and stool.
B. Apply powder to the perineum. Powder can cause clumping when mixed with moisture, increasing friction and leading to skin irritation. It is not the preferred method for preventing skin breakdown in incontinent patients.
C. Provide a donut-shaped pillow to sit on. Donut-shaped pillows create pressure points around the edges, which can worsen pressure injuries rather than prevent them. A pressure-relieving cushion is a better alternative.
D. Use an antimicrobial soap to clean skin. Harsh soaps can strip the skin of its natural protective oils, leading to dryness and irritation. A mild, pH-balanced cleanser is recommended for skin care.
E. Place a foam pad on the bed. Foam pads help redistribute pressure and reduce friction, lowering the risk of pressure injuries for patients who have limited mobility and spend extended time in bed.
F. Ensure the client slides up in bed on their own. Allowing the client to slide in bed increases friction and shearing forces, leading to skin breakdown. Assisted repositioning is necessary to prevent injury.
G. Two-person assist to move up in bed using a slide sheet. Using a slide sheet with assistance minimizes friction and shear, which are significant contributors to pressure ulcers. This method helps protect fragile skin.
H. Elevate the head of the bed above 30 degrees. Elevating the bed above 30 degrees increases pressure on the sacrum and coccyx, heightening the risk of skin breakdown. A lower elevation is preferred unless contraindicated.
I. Request a physical therapy consult. A physical therapy consult can help improve mobility, strength, and positioning techniques, reducing prolonged pressure on vulnerable areas and promoting skin integrity.

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Correct Answer is A

Explanation

A. Increase in monocytes and macrophages. Monocytes and macrophages are key immune cells involved in the inflammatory response. Monocytes migrate to the affected tissue, where they differentiate into macrophages and help clear pathogens, dead cells, and debris. Their presence indicates an ongoing or chronic inflammatory process.
B. Predominance of megakaryocytes. Megakaryocytes are large bone marrow cells responsible for platelet production. They are not involved in inflammation and are typically found in the bone marrow, not in inflamed tissues.
C. Presence of fibroblasts and collagen. Fibroblasts and collagen are associated with tissue repair and scar formation rather than active inflammation. Their presence suggests healing and fibrosis rather than an acute inflammatory response.
D. Prevalence of dead neutrophils. Dead neutrophils are a hallmark of pus formation (suppuration) in bacterial infections but do not necessarily indicate ongoing inflammation. Neutrophils are the first responders in acute inflammation, but their presence alone does not define an inflammatory process—the presence of active immune cells like macrophages is more indicative.

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

Based on the client's history, physical, and laboratory findings, the priority need will be to treat the infection (cellulitis). In addition, the client will need interventions to manage complications, especially deep tissue injury and impaired circulation.

Rationale:

The infection (cellulitis) is the primary concern, as indicated by redness, warmth, swelling, and systemic symptoms like muscle aches. Immediate antibiotic therapy is crucial.

Deep tissue injury is a potential complication due to prolonged inflammation, swelling, and impaired circulation, which can lead to tissue damage.

Impaired circulation is a significant risk in a client with diabetes and peripheral vascular disease, as it can slow healing and increase the likelihood of further complications such as ulcers or necrosis.

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Exhibits The nurse reviews the client's data. After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which histologic finding in an affected area of the body suggests the presence of an inflammatory process?

Correct Answer is A

Explanation

Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"B","dropdown-group-3":"C"}

Explanation

The nurse is caring for a young adult who reports uncontrolled acne vulgaris. Which pathological findings should the nurse observe on inspection of skin areas commonly affected in acne vulgaris?

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Exhibits Click to indicate which education instructions the nurse should include to prevent future cellulitis and promote healing when preparing the client for discharge. Each column must have at least one response selected.

Exhibits

The nurse reviews the client's data.

After collaboration with the wound care nurse, which intervention(s) should the primary nurse perform to reduce risk of skin injury? Select all that apply.