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 A

Explanation

Choice A rationale

The brain stem controls vital functions, including respiration. Damage to the brain stem, especially the medulla oblongata, can impair respiratory control, leading to the need for mechanical ventilation.

Choice B rationale

The parietal lobe is responsible for sensory processing and does not directly influence respiratory functions. Damage here would more likely affect sensation and spatial awareness.

Choice C rationale

The occipital lobe is primarily responsible for visual processing. Injury to this area would result in visual deficits rather than impaired respiration.

Choice D rationale

The frontal lobe is involved in cognitive functions, voluntary movement, and speech production, but it does not control respiration. Damage here would affect higher cognitive functions and motor planning.

A. Dryness of the eyes. B. Skin peeling on eyelids. C. Pruritus of the eyes. D. Burning of the eyes.

Correct Answer is ["A","B","D"]

Explanation

Choice A rationale

Dryness of the eyes, or xerophthalmia, is a common symptom of keratoconjunctivitis. It indicates the involvement of the conjunctiva and cornea, often seen in conditions like Stevens-Johnson syndrome or toxic epidermal necrolysis.

Choice B rationale

Skin peeling on the eyelids suggests severe involvement of the ocular adnexa and can be a sign of advancing keratoconjunctivitis. This symptom reflects significant mucocutaneous damage.

Choice C rationale

Pruritus, or itching, is less specific for keratoconjunctivitis and more commonly associated with allergic reactions or less severe irritations. It is not a primary indicator of the disease's progression.

Choice D rationale

Burning of the eyes is a symptom of keratoconjunctivitis, indicating inflammation and irritation of the conjunctiva and cornea. This symptom helps in identifying the progression of the condition. .

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

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Naxlex Comprehensive Predictor Exams

A client who has suffered a stroke is unable to maintain respiration and is intubated and placed on mechanical ventilator support. What portion of the brain is most likely responsible for the inability to breathe?

Correct Answer is A

Explanation

The nurse is assessing a client with toxic epidermal necrolysis (TEN). What assessment data would indicate that the client may be progressing to keratoconjunctivitis? Select all that apply.

Correct Answer is ["A","B","D"]

Explanation

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