What Nursing Diagnosis would be a priority for a client who has had a large surgical wound from recent colon surgery, the client is obese, and the client is taking corticosteroid medications?
Anxiety.
Self-care Deficit.
Risk for Infection.
Risk for Imbalanced Nutrition.
The Correct Answer is C
Choice A rationale:
Anxiety is a valid concern for any client undergoing surgery, but it is not the priority nursing diagnosis in this case. The client's risk for infection is more pressing due to the following factors:
Large surgical wound: Wounds provide a potential entry point for pathogens.
Obesity: Excess adipose tissue can impair wound healing and increase the risk of infection.
Corticosteroid medications: These medications suppress the immune system, making it more difficult for the body to fight off infection.
Choice B rationale:
Self-care Deficit may be a concern if the client has difficulty caring for the surgical wound or maintaining hygiene due to obesity. However, it is not the priority diagnosis in this case. The focus should be on preventing infection, which would also help to address any self-care deficits.
Choice D rationale:
Risk for Imbalanced Nutrition is a relevant diagnosis for a client who has had colon surgery, as they may experience changes in appetite, digestion, or absorption of nutrients. However, it is not the priority diagnosis in this scenario. Preventing infection is crucial to ensure proper wound healing and overall recovery.
Choice C rationale:
Risk for Infection is the priority nursing diagnosis for this client due to the following risk factors: Large surgical wound: The wound provides a potential entry point for bacteria and other pathogens.
Obesity: Excess adipose tissue can impair wound healing by reducing blood flow to the area and increasing the risk of wound dehiscence (separation of wound edges). This can create a favorable environment for bacterial growth.
Corticosteroid medications: These medications suppress the immune system, making it more difficult for the body to fight off infection.
Nursing interventions to address Risk for Infection:
Assess the wound regularly for signs of infection, such as redness, swelling, warmth, pain, or purulent drainage. Implement strict aseptic technique when caring for the wound.
Teach the client about proper wound care and hygiene practices.
Monitor the client for signs of systemic infection, such as fever, chills, or malaise. Administer antibiotics as prescribed.
Encourage adequate nutrition and hydration to support wound healing.
Collaborate with the healthcare team to manage the client's risk factors for infection.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Urinary retention is the inability to completely empty the bladder. It is a common symptom of BPH, as the enlarged prostate can press on the urethra and obstruct the flow of urine. This can lead to several characteristic symptoms, including:
Feeling of incomplete bladder emptying: Patients often feel as though they haven't fully emptied their bladder, even after urinating.
Straining to urinate: It may take extra effort to initiate and maintain a urine stream.
Weak urine stream: The force of the urine stream may be noticeably reduced.
Intermittent urine stream: The flow of urine may start and stop repeatedly.
Post-void dribbling: Urine may continue to drip after urination has seemingly ended.
Urinary frequency: The need to urinate frequently, often at night (nocturia).
Urgency: A sudden, compelling need to urinate that may be difficult to postpone.
Bladder pain or discomfort: Pressure or pain in the lower abdomen, often associated with a full bladder. Pathophysiology:
Bladder outlet obstruction: The enlarged prostate physically compresses the urethra, the tube that carries urine from the bladder to the outside of the body. This obstruction makes it difficult for urine to flow freely, leading to incomplete bladder emptying.
Detrusor muscle dysfunction: The detrusor muscle, which forms the bladder wall, may become weakened or overactive due to the constant strain of trying to empty against resistance. This can further impair bladder emptying.
Neurological factors: In some cases, nerve damage or dysfunction may contribute to urinary retention, particularly in men with diabetes or neurological conditions.
Additional insights:
Chronic urinary retention can result in serious complications, such as bladder stones, urinary tract infections, and kidney damage.
Acute urinary retention is a medical emergency that requires immediate catheterization to relieve the bladder and prevent further complications.
Treatment for urinary retention typically involves medications to relax the prostate and bladder muscles, as well as lifestyle modifications such as limiting fluid intake before bedtime. In some cases, surgical intervention may be necessary to reduce the size of the prostate or widen the urethra.
Correct Answer is C
Explanation
Choice A rationale:
Circular turns involve wrapping the bandage around the limb in a continuous circle, with each layer overlapping the previous one. While this technique is effective for securing dressings on cylindrical body parts like the arm or thigh, it's not ideal for joints like the ankle. Circular turns can constrict movement and potentially impair circulation, especially if applied too tightly. Additionally, they don't provide adequate compression for wounds that require it.
Choice B rationale:
Figure-of-eight turns create a cross-over pattern around the joint, resembling the number 8. This technique offers better flexibility and movement compared to circular turns, but it's still not the most appropriate for the ankle. The cross-over pattern can create uneven pressure points and potentially lead to discomfort or even skin irritation. Moreover, it might not provide sufficient compression for wound management.
Choice C rationale:
Spiral turns involve wrapping the bandage diagonally, ascending or descending the limb, with each layer overlapping the previous one by about half its width. This technique is considered the most suitable for bandaging joints like the ankle for several reasons:
Conforms to Joint Contours: Spiral turns naturally mold to the shape of the ankle, providing even pressure distribution and avoiding constriction points. This ensures comfort and maintains proper blood flow.
Allows for Movement: The diagonal pattern accommodates the natural flexion and extension of the ankle joint, allowing for greater mobility without compromising bandage integrity.
Provides Effective Compression: Spiral turns can be applied with varying degrees of compression to suit the needs of the wound and surrounding tissue. This can help control bleeding, reduce swelling, and promote healing.
Easy to Apply and Adjust: Spiral turns are relatively straightforward to apply and can be easily adjusted if needed, making them adaptable to different wound sizes and patient needs.
Choice D rationale:
Recurrent bandaging involves wrapping the bandage back and forth over the same area multiple times, creating a thicker layer. This technique is primarily used for stumps or areas requiring significant padding and absorption. It's not typically used for bandaging joints like the ankle, as it can create excessive bulk and potentially restrict movement.
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