The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply.
Palpate the client's skin for moisture, temperature, and texture.
Ask the client whether the wound bed or surrounding skin itches.
Measure and assess the client's wound bed, size, edges, and margins.
Evaluate the client's level of pain, using a numeric value pain scale.
Review the client's prothrombin time test and international normalized ratio.
Correct Answer : A,C,D
Choice A rationale
Palpating the client's skin for moisture, temperature, and texture is essential in wound management. This allows the nurse to assess for signs of infection or inflammation, which can affect the wound healing process. Moisture can indicate excessive drainage or sweating that might macerate the skin, while changes in temperature and texture can signify infection or poor blood flow.
Choice B rationale
While asking the client whether the wound bed or surrounding skin itches may provide some information about the client's comfort, it is not a primary intervention for wound management. Itching can be a sign of healing or irritation, but it does not provide direct information on the wound's condition.
Choice C rationale
Measuring and assessing the wound bed, size, edges, and margins are critical steps in wound management. This helps to determine the progression of healing, the presence of necrotic tissue, and any changes in the wound over time. Accurate measurement and documentation are essential for developing an appropriate care plan.
Choice D rationale
Evaluating the client's level of pain using a numeric value pain scale is important in wound management. Pain can indicate underlying issues such as infection, poor perfusion, or neuropathy. Assessing pain helps guide interventions to provide comfort and address any complications that may arise.
Choice E rationale
Reviewing the client's prothrombin time test and international normalized ratio is not a standard intervention for wound management. These tests are more relevant to assessing the client's coagulation status, which may be important for surgical or anticoagulant therapy but not directly for wound care.
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Related Questions
Correct Answer is D
Explanation
Choice A rationale
Pressing the bones on the neck does not adequately assess for rigidity and may cause discomfort without providing useful information about the neurologic status.
Choice B rationale
Moving the head toward both sides is a method used to assess range of motion but does not specifically assess for neck rigidity, which requires specific positioning and movement.
Choice C rationale
Lightly tapping the lower portion of the neck to detect sensation does not assess for rigidity; it may be used to test sensory function rather than muscular stiffness or tension.
Choice D rationale
Moving the head and chin toward the chest is the standard method to assess for neck rigidity, especially in cases of suspected meningitis. This movement can reveal stiffness or resistance, which are key indicators of neurologic involvement.
Correct Answer is D
Explanation
Choice A rationale
Cerebrospinal fluid (CSF) does not produce cerebral neurotransmitters. Neurotransmitters are produced by neurons in the brain and nervous system.
Choice B rationale
CSF provides a protective barrier to some extent, but its primary function is not to act as a barrier to bacteria. The blood-brain barrier primarily serves this function.
Choice C rationale
CSF helps maintain a stable environment in the central nervous system but is not primarily an insulator for maintaining constant temperature. Its thermal properties are secondary.
Choice D rationale
The primary function of CSF is to cushion and protect the brain and spinal cord from mechanical injury. It also helps maintain the brain's buoyancy and provides a stable environment for the central nervous system.
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