Three days ago, a client was admitted from home with a reported pressure injury. The provider and wound care nurse were at the bedside.
Which statement best describes the most critical aspect of the client's pressure injury and current treatment?
The client was admitted three days ago.
The pressure injury was at stage 4.
The client reported pain as a 2 on a scale from 0 to 10.
The dressing was reapplied and sealed.
The Correct Answer is B
Choice A rationale
The client was admitted three days ago. This statement is factual, but it does not directly address the current condition of the client’s pressure injury. The time of admission is not as relevant as the progression and treatment of the wound. Therefore, while this choice is accurate, it is not the most critical piece of information in this context.
Choice B rationale
The pressure injury was at stage 4. This is the correct answer. Stage 4 pressure ulcers involve full-thickness skin loss potentially extending into the subcutaneous tissue layer. Stage 4 pressure ulcers extend even deeper, exposing underlying muscle, tendon, cartilage or bone.
The presence of slough, eschar, and tunnels, as well as the size of the wound, are consistent with a stage 4 pressure ulcer. The treatment provided, including debridement and negative
pressure wound therapy, is also typical for this stage of pressure injury. Therefore, this choice accurately describes the client’s condition.
Choice C rationale
The client reported pain as a 2 on a scale from 0 to 10. While it’s important to monitor the client’s pain levels, this information alone does not provide a comprehensive understanding of the client’s condition. Pain can be subjective and varies from person to person. A score of 2 indicates minor pain, which is manageable and does not significantly interfere with the client’s daily activities. However, this does not negate the severity of a stage 4 pressure injury.
Choice D rationale
The dressing was reapplied and sealed. This statement describes one aspect of the wound care process. Negative pressure wound therapy involves the application of a vacuum through a special sealed dressing. The dressing is crucial in creating a moist healing environment, reducing edema, and promoting wound healing. However, the reapplication and sealing of the dressing alone do not provide a complete picture of the client’s condition or the severity of the pressure injury.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Group discussions can be beneficial for sharing experiences and learning from others, but they do not provide the hands-on, practical experience that is characteristic of the psychomotor learning domain.
Choice B rationale
-answer meetings can be useful for clarifying doubts and enhancing understanding, but they do not offer the opportunity for physical manipulation of objects or execution of procedures, which is central to psychomotor learning.
Choice C rationale
Practice sessions can be an effective method for psychomotor learning as they allow for repeated performance of a skill. However, in the context of teaching adolescents with newly placed ostomies, role play might be more beneficial as it allows for the simulation of real-life scenarios and the practice of problem-solving skills in a safe and controlled environment.
Choice D rationale
Role play is a method that falls under the psychomotor domain of learning. It involves acting out scenarios and provides an opportunity for hands-on practice and learning. In the context of adolescents with newly placed ostomies, role play can help them practice self-care tasks related to ostomy management in a safe and supportive environment.
Correct Answer is D
Explanation
Choice A rationale
Cucumbers are a good source of hydration due to their high water content, but they are not particularly high in potassium.
Choice B rationale
Corn is a versatile vegetable that provides a good source of fiber, but it is not particularly high in potassium.
Choice C rationale
Asparagus is a nutrient-rich vegetable known for its diuretic properties, but it is not particularly high in potassium.
Choice D rationale
Avocados are a nutrient-dense fruit that is high in healthy fats and also a good source of potassium. They are a great food choice for a client at risk for hypokalemia.
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