The nurse is caring for a client who is immobile and developed a stage IV pressure injury on the sacrum. The nurse identifies eschar in the wound bed. Which intervention is most important for the nurse to implement?

Place a foam surface on top of the mattress.

Raise the head of the bed only to 30 degrees.

Perform passive range of motion exercises.

Increase the daily intake of vitamin C.

Answer and Explanation

The Correct Answer is B

Rationale:

A. Place a foam surface on top of the mattress: A foam surface may help reduce pressure, but for a stage IV pressure injury with eschar, this alone is insufficient. More advanced pressure redistribution systems are needed for adequate management of severe wounds.

B. Raise the head of the bed only to 30 degrees: Limiting the head-of-bed elevation helps reduce shear forces, which worsen pressure injuries, especially over the sacrum. This intervention is critical for preventing further tissue damage and promoting healing of deep wounds with eschar.

C. Perform passive range of motion exercises: While passive ROM supports circulation and prevents contractures, it does not directly address pressure relief or eschar management. It's beneficial, but not the top priority for treating a stage IV ulcer.

D. Increase the daily intake of vitamin C: Vitamin C supports collagen synthesis and immune function, aiding wound healing. However, nutrition alone cannot address mechanical factors like pressure and shear, which are primary contributors to pressure injury progression.

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

Explanation

Rationale for Correct Choices

Neglect: The client presents with signs of poor hygiene, untreated pressure injuries, confinement to bed without a clear medical reason, and a reduction in social interaction and autonomy. These factors collectively indicate neglect, which is the failure of a caregiver to meet the basic physical, emotional, and social needs of a dependent adult.
Adult Protective Services: Adult Protective Services is the appropriate authority to report suspected abuse or neglect of older adults living in private homes. As a mandated reporter, the nurse is legally required to report suspected elder mistreatment to APS to initiate an investigation and protect the client.

Rationale for Incorrect Choices

Sexual abuse: There are no indicators such as bruising in private areas, fear of the caregiver, or behavioral cues that might suggest sexual trauma. The case centers on physical neglect, not sexual abuse.
Financial exploitation: The client has not reported any unauthorized financial activity, and there is no evidence of the caregiver misusing or controlling the client’s finances. This makes financial exploitation an unlikely concern.
Long Term Care Program: This agency oversees long-term care facilities like nursing homes. Since the client resides in a private home, the situation falls outside the jurisdiction of this program.
State Department of Health: The Department of Health primarily monitors healthcare providers and facilities, not private caregiving situations. Therefore, it is not the correct agency to report suspected elder abuse in this context.

A. Peripheral neuropathy. B. Right lower abdominal pain. C. Confusion. D. Depression.

Correct Answer is C

Explanation

Rationale:
A. Peripheral neuropathy: Although peripheral neuropathy may occur with chronic alcohol use, it is more commonly associated with peripheral nerve damage over time and is not the hallmark of Wernicke's syndrome.

B. Right lower abdominal pain: This is not characteristic of Wernicke's syndrome and is more indicative of appendicitis or gastrointestinal conditions.

C. Confusion: Wernicke’s syndrome (Wernicke’s encephalopathy) is a neurologic disorder caused by thiamine deficiency, often related to chronic alcoholism. Key symptoms include confusion, ataxia, and ophthalmoplegia, making confusion a central assessment to guide care.

D. Depression: While mood disorders can coexist in individuals with alcohol use disorder, depression is not a defining feature of Wernicke’s syndrome and does not guide immediate nursing priorities for this diagnosis.

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The nurse is caring for a client who is immobile and developed a stage IV pressure injury on the sacrum. The nurse identifies eschar in the wound bed. Which intervention is most important for the nurse to implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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

Explanation

A client is admitted with the diagnosis of Wernicke's syndrome. Which assessment finding should the nurse use when developing the client's plan of care?

Correct Answer is C

Explanation

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