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The nurse reminds the 85-year-old patient that his healing will be slower because of age-related changes such as: (Select all that apply.)

Increased immunity.

Atherosclerosis.

Slow metabolism.

Excessive production of blood factors.

Diminished lung function.

Answer and Explanation

Correct Answer : A,B,C,E

Choice A rationale:

Increased immunity is not a characteristic of aging. In fact, immunity decreases with age, which can slow healing.

Choice B rationale:

Atherosclerosis, or hardening of the arteries, can reduce blood flow to tissues and slow healing.

Choice C rationale:

Metabolism slows with age, which can delay the body’s ability to repair and regenerate tissues.

Choice D rationale:

Excessive production of blood factors is not a characteristic of aging. Blood factors are typically produced in response to injury or illness.

Choice E rationale:

Diminished lung function can reduce oxygen supply to tissues, slowing healing.

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Correct Answer is C

Explanation

Choice A rationale:

Stage 3 pressure injuries involve full-thickness skin loss, but not exposure of fascia.

Choice B rationale:

Stage 2 pressure injuries involve partial-thickness loss of skin with exposed dermis.

Choice C rationale:

Stage 4 pressure injuries involve full-thickness skin and tissue loss with exposed or directly palpable fascia.

Choice D rationale:

Stage 1 pressure injuries involve non-blanchable erythema of intact skin.

A. Ask someone to quickly get an abdominal binder. B. Assist the patient in a supine position. C. Seat the patient in a nearby chair. D. Instruct the patient to pant to reduce abdominal tension.

Correct Answer is B

Explanation

Choice A rationale:

Asking someone to quickly get an abdominal binder is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position to prevent further injury.

Choice B rationale:

Assisting the patient to a supine position is the correct action. This is because the patient’s statement may indicate dehiscence (separation of the wound edges), and placing the patient in a supine position with the knees bent can reduce tension on the wound and prevent further injury.

Choice C rationale:

Seating the patient in a nearby chair is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

Choice D rationale:

Instructing the patient to pant to reduce abdominal tension is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.

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The nurse reminds the 85-year-old patient that his healing will be slower because of age-related changes such as: (Select all that apply.)

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Naxlex Comprehensive Predictor Exams

The nurse on the unit is going to perform wound care for her patient.After removing the soiled dressing, the following wound is noted to have full-thickness skin and tissue loss with exposed palpable fascia.

Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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