The nurse documenting an acute open wound should include which characteristics? Select all that apply.

Wound size.

Wound bed.

Periwound skin.

Pattern of eruption.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

Documenting wound size includes measuring the length, width, and depth of the wound to track the healing process and plan appropriate interventions.

Choice B rationale

The wound bed should be assessed for tissue type (granulation, slough, or eschar), color, and the presence of any exudate or infection.

Choice C rationale

The periwound skin is the area around the wound which should be assessed for color, temperature, swelling, and signs of maceration or excoriation.

Choice D rationale

Pattern of eruption is more relevant to dermatological conditions such as rashes or lesions, and not a primary focus for documenting acute open wounds.

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Correct Answer is B

Explanation

Choice A rationale

Dysfunction in the cerebrum would likely result in different types of posturing, such as decorticate posturing, rather than decerebrate. The cerebrum is involved in controlling voluntary motor functions and damage here typically does not lead to decerebrate posturing.

Choice B rationale

Dysfunction in the brain stem results in decerebrate posturing, characterized by rigid extension of the arms and legs, downward pointing of the toes, and backward arching of the head. The brain stem is crucial for controlling basic life functions and its impairment leads to severe motor response issues.

Choice C rationale

Dysfunction in the spinal column typically does not lead to decerebrate posturing but may lead to different types of paralysis or movement issues depending on the location and severity of the damage.

Choice D rationale

Dysfunction in the motor cortex usually leads to abnormalities in voluntary movement, muscle tone, and coordination rather than decerebrate posturing which is more linked to brain stem issues.

A. Ativan. B. Cerebyx. C. Phenobarbital. D. Valium.

Correct Answer is C

Explanation

Choice A rationale

Ativan (lorazepam) is used for immediate control of seizures but is not used for long-term maintenance.

Choice B rationale

Cerebyx (fosphenytoin) is used for seizure control but is generally not used for long-term maintenance.

Choice C rationale

Phenobarbital is a barbiturate that is commonly used for long-term maintenance to prevent seizures. It works by depressing the central nervous system and reducing the spread of seizure activity.

Choice D rationale

Valium (diazepam) is used for acute seizure control but not for long-term seizure prevention.

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The nurse documenting an acute open wound should include which characteristics? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse observes that decerebrate posturing is a comatose client's response to painful stimuli. Decerebrate posturing as a response to pain indicates:

Correct Answer is B

Explanation

Which of the following drugs may be used after a seizure to maintain a seizure-free state?

Correct Answer is C

Explanation

A client with increased intracranial pressure has a cerebral perfusion pressure (CPP) of 40 mm Hg. This CPP reading is considered:

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A client is being treated for prolonged diarrhea. Which foods should the nurse encourage the client to consume?

A client's orders include a wound dressing using an autolytic debriding agent. The nurse providing discharge instructions to the client should include which statement?

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A client in the emergency department has a suspected neurologic disorder. To assess gait, the nurse asks the client to take a few steps; with each step, the client's feet make a half circle. To document the client's gait, the nurse should use which term?