The client is at risk for impaired skin integrity related to the need for several weeks of bed rest. The nurse evaluates the client after one week and finds the skin integrity is not impaired. In evaluating the plan of care, what is the nurse’s best action?
Remove the nursing diagnosis in the plan of care since it has not occurred.
Keep the nursing diagnosis in the plan of care the same since the risk factors are still present.
Modify the nursing diagnosis in the plan of care to impaired skin integrity.
Change the nursing diagnosis in the plan of care to impaired mobility.
The Correct Answer is B
Choice A reason: Removing the nursing diagnosis in the plan of care since it has not occurred is not a good action, because it does not account for the possibility of future impairment. The client is still at risk for impaired skin integrity due to the prolonged bed rest, and the nurse should continue to monitor and prevent any skin breakdown.
Choice B reason: Keeping the nursing diagnosis in the plan of care the same since the risk factors are still present is the best action, because it reflects the current situation and the potential problem. The client has not developed impaired skin integrity, but the risk factors have not changed. The nurse should maintain the interventions that have been effective in preventing skin impairment, such as turning, repositioning, moisturizing, and inspecting the skin.
Choice C reason: Modifying the nursing diagnosis in the plan of care to impaired skin integrity is not a good action, because it does not match the data. The client has not shown any signs of impaired skin integrity, such as redness, blanching, breakdown, or ulceration. The nurse should not change the diagnosis based on assumptions or predictions, but on evidence.
Choice D reason: Changing the nursing diagnosis in the plan of care to impaired mobility is not a good action, because it does not address the original problem. The client may have impaired mobility due to the bed rest, but that is not the focus of the question. The question is about the risk for impaired skin integrity, which is a different issue that requires different interventions. The nurse should not ignore or replace the existing diagnosis without justification.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Culturing the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Culturing the wound is a procedure that involves collecting a sample of the wound drainage and sending it to the laboratory for analysis, which can help identify the type and source of infection. Culturing the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a sterile technique.
Choice B reason: Applying topical ointment to the wound is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Applying topical ointment to the wound is a procedure that involves applying a medication or a dressing to the wound site, which can help prevent or treat infection, inflammation, or pain. Applying topical ointment to the wound is an important intervention, but it should be done after inspecting the wound and assessing the drainage, and with a medical order and a clean technique.
Choice C reason: Inspecting the wound and assessing the drainage is the nurse's priority assessment for this client, because it is the most urgent and relevant action. Inspecting the wound and assessing the drainage is a process that involves observing and measuring the wound site and the wound exudate, which can reveal the presence and severity of infection, injury, or healing. Inspecting the wound and assessing the drainage is an essential assessment, as it can guide the diagnosis, treatment, and evaluation of the client's condition.
Choice D reason: Calling the provider to initiate antibiotics is not the nurse's priority assessment for this client, because it is not the most urgent and relevant action. Calling the provider to initiate antibiotics is a communication that involves reporting the client's situation and requesting a prescription for an antimicrobial agent, which can help fight or prevent infection. Calling the provider to initiate antibiotics is an important communication, but it should be done after inspecting the wound and assessing the drainage, and with the necessary data and documentation.
Correct Answer is A
Explanation
Choice A reason: A client with leukemia is a susceptible host most at risk for infection. Leukemia is a type of cancer that affects the blood cells, especially the white blood cells, which are responsible for fighting infections. Leukemia causes the production of abnormal and immature white blood cells that cannot function properly and crowd out the normal ones. This leads to a condition called leukopenia, which is a low level of white blood cells. Leukopenia makes the client more vulnerable to infection by reducing the immune system's ability to defend against pathogens.
Choice B reason: A child who is immunized is not a susceptible host most at risk for infection. Immunization is a process that stimulates the immune system to produce antibodies against a specific disease. Immunization protects the child from getting infected by the disease or reduces the severity of the infection if it occurs. Immunization also prevents the spread of the disease to other people who are not immunized or who are immunocompromised.
Choice C reason: A 60yearold client is not a susceptible host most at risk for infection. Age is a factor that may influence the susceptibility to infection, but it is not the most important one. Older adults may have a weaker immune system due to aging, chronic diseases, or medications, but they may also have a stronger immune memory due to previous exposure to pathogens. The risk of infection in older adults depends on their overall health status, lifestyle, and preventive measures.
Choice D reason: A hospitalized 35yearold client is not a susceptible host most at risk for infection. Hospitalization is a factor that may increase the exposure to infection, but it is not the most significant one. Hospitalized clients may encounter various sources of infection, such as health care workers, other clients, medical equipment, or invasive procedures, but they may also receive adequate infection control measures, such as hand hygiene, isolation, sterilization, or prophylaxis. The risk of infection in hospitalized clients depends on their diagnosis, treatment, and compliance.
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