The nurse is providing health teaching to a client with a wound. Which of the following should be included in the teaching?

Adequate nutrition delays wound healing and increases risk of infection.

Chronic wounds heal better in a dry, open environment so leave them open to air.

Fat tissue heals more rapidly because there is less vascularization.

Long term steroid use diminishes the inflammatory response and delays wound healing.

Answer and Explanation

The Correct Answer is D

A. Adequate nutrition actually promotes wound healing. Poor nutrition, especially a lack of protein and vitamins, delays healing and increases the risk of infection.

B. Chronic wounds heal better in a moist environment rather than a dry one. Moist wound healing promotes cell migration and prevents scab formation, improving healing.

C. Fat tissue does not heal more rapidly. In fact, it heals more slowly due to decreased vascularization, which impairs oxygen delivery and nutrient supply to the tissue.

D. Long-term steroid use diminishes the body’s inflammatory response, reducing the body's ability to initiate the healing process. This delay in inflammation can lead to slower wound healing and a higher risk of infection.

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

Explanation

A. A client with right-sided heart failure and 4+ edema is at risk for pressure ulcers due to fluid accumulation, which can impair circulation and increase the likelihood of skin breakdown.

B. A client who is ambulatory is at a low risk for pressure ulcers because frequent movement reduces the risk of prolonged pressure on any one area.

C. A client with type 1 diabetes mellitus and hyperglycemia is at risk for pressure ulcers because high blood glucose levels can impair wound healing and affect skin integrity.

D. A client with protein-calorie malnutrition is at a significant risk for pressure ulcers due to inadequate nutrition, which weakens the skin and impairs the body’s ability to repair tissue damage.

E. A client with postoperative delirium may have decreased mobility and cognitive awareness, making it harder for them to reposition themselves, thereby increasing their risk of pressure ulcers.

A. Apply cornstarch to keep the skin dry. B. Provide the client with a diet high in protein. C. Massage bony prominences to promote circulation. D. Reposition the client every 3 hr.

Correct Answer is B

Explanation

A. Applying cornstarch can absorb moisture; however, it may not be the most effective method to maintain skin integrity and can cause friction when applying.

B. A diet high in protein is essential for skin health and repair, as it supports tissue regeneration and helps prevent skin breakdown in vulnerable clients.

C. Massaging bony prominences is not recommended, as it may cause further tissue damage or disrupt circulation. Instead, padding and reducing pressure on these areas is more beneficial.

D. Repositioning the client every 3 hours may not be frequent enough for someone at high risk for skin breakdown; generally, repositioning should occur at least every 2 hours to alleviate pressure.

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The nurse is providing health teaching to a client with a wound. Which of the following should be included in the teaching?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is providing care for four clients on a medical-surgical unit. Which of the following clients should the nurse identify as being at risk for the development of pressure ulcers? (Select all that apply.)

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

Explanation

A nurse is caring for an older adult client who is at risk for skin breakdown. Which of the following interventions should the nurse use to help maintain the integrity of the client's skin?

Correct Answer is B

Explanation

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