The nurse is caring for a patient who has had a pressure injury. When assessing the wound, which finding causes the greatest concern for the nurse?

Amber fluid

Clear drainage

Purulent, draining wound

Blood-tinged fluid

Answer and Explanation

The Correct Answer is C

Choice A reason: Amber fluid is typically a sign of serous exudate, which is a normal part of the inflammatory process and wound healing. It indicates the body's immune response to the injury and is generally not a cause for concern unless the volume significantly increases or changes in appearance.

Choice B reason: Clear drainage, or serous fluid, is also a normal finding in wound healing. It indicates that the wound is exuding plasma, which helps to keep the wound moist and supports the healing process. This type of drainage is typically not worrisome unless there are other signs of infection or complications.

Choice C reason: Purulent, draining wound is a major concern as it indicates the presence of pus, which is often a sign of infection. Purulent drainage can be yellow, green, or brown and is usually thick and malodorous. The presence of pus suggests that there are bacteria or other pathogens in the wound, and immediate medical intervention is necessary to prevent further complications and promote healing.

Choice D reason: Blood-tinged fluid, or serosanguinous drainage, is common in fresh wounds or after debridement. It indicates a mixture of plasma and red blood cells and can be seen in the early stages of wound healing. While it is generally not alarming, the nurse should monitor the volume and changes in the drainage to ensure there are no signs of excessive bleeding or infection.

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Correct Answer is D

Explanation

Choice A reason: Hypotension, chills, and thirst are not characteristic signs and symptoms of a thyroid storm. Hypotension generally indicates low blood pressure, while chills and thirst are less specific symptoms that do not particularly point to thyroid storm.

Choice B reason: Lethargy, confusion, and bradycardia are not typical indicators of a thyroid storm. These symptoms might be present in other conditions but are not generally associated with the severe hypermetabolic state seen in thyroid storms.

Choice C reason: Bradycardia, hypotension, and low urine output are also not typical signs of a thyroid storm. Bradycardia (slow heart rate) and hypotension (low blood pressure) are more likely associated with severe hypothyroidism or other conditions, not the hyperactive state of a thyroid storm.

Choice D reason: Fever, tachycardia, and tremors are classic signs of a thyroid storm. A thyroid storm is a life-threatening condition characterized by an excessive amount of thyroid hormones, leading to hypermetabolic activity. This results in symptoms like a high fever, rapid heart rate (tachycardia), and tremors.

A. Offer high-calorie protein snacks between meals and at bedtime. B. Encourage increased intake of whole grains and vegetables. C. Encourage rest before meals. D. Provide a large glass of juice with each meal.

Correct Answer is ["A","C"]

Explanation

Choice A reason: Offering high-calorie protein snacks between meals and at bedtime is appropriate for a patient with COPD who is losing weight and eating very little. These snacks can help meet their nutritional needs and provide the extra calories and protein necessary to prevent muscle wasting and support overall health.

Choice B reason: While increasing the intake of whole grains and vegetables is generally healthy, it may not be the priority for a patient who has lost significant weight and needs to focus on higher-calorie, nutrient-dense foods. The primary goal is to address the calorie and protein deficit first.

Choice C reason: Encouraging rest before meals is beneficial as it helps conserve energy for eating. Patients with COPD often experience fatigue, which can reduce their appetite and ability to eat. Resting before meals can help them feel more energetic and better able to consume their meals.

Choice D reason: Providing a large glass of juice with each meal is not ideal for increasing calorie and protein intake. While juice can provide some calories and nutrients, it is not a good source of protein. Additionally, large volumes of liquid can create a feeling of fullness, reducing the patient's appetite for nutrient-dense foods.

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The nurse is caring for a patient who has had a pressure injury. When assessing the wound, which finding causes the greatest concern for the nurse?

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Naxlex Comprehensive Predictor Exams

Adlent has been diagnosed with hyperthyroidism. Which signs and symptoms may indicate thyroid storm, a complication of this disorder?

Correct Answer is D

Explanation

A patient with chronic obstructive pulmonary disease (COPD) on daily prednisone therapy has been eating very little and has lost weight. Which interventions are appropriate for the nurse to include in the care plan? Select all that apply.

Correct Answer is ["A","C"]

Explanation

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