Which action should the nurse take after assessing a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen?

Apply warm soaks to reduce the inflammation.

Notify the health care provider immediately of the infection.

Place the client on contact (wound) precautions.

Document the findings and continue to monitor the wound.

Answer and Explanation

The Correct Answer is D

. Document the findings and continue to monitor the wound. This is because a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen is likely in the inflammatory phase of wound healing. This phase is characterized by hemostasis, chemotaxis, and increased vascular permeability, which can

cause redness and swelling. The crust along the edges is formed by the clotting of blood and platelets.

These are normal signs of wound healing and do not indicate infection or complications.

Choice A is wrong because applying warm soaks to reduce inflammation can interfere with the natural process of wound healing and increase the risk of infection.

Choice B is wrong because notifying the health care provider immediately of the infection is not necessary unless there are other signs of infection such as fever, pus, foul odor, or increased pain.

Choice C is wrong because placing the client on contact (wound) precautions is not required for a 2-day-old wound that is not infected or draining. Wound precautions are only indicated for wounds that are colonized or infected by multidrug-resistant organisms.

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Correct Answer is C

Explanation

This would help the client to feel valued, respected and involved in their own care, which can enhance their self-esteem.

Choice A is wrong because adding a nursing diagnosis of lowered self-esteem to the care plan does not address the underlying causes of the problem or provide any interventions to improve it.

It may also label the client and make them feel worse.

Choice B is wrong because giving praise for every decision the client makes is not realistic or sincere.

It may also undermine the client’s confidence and autonomy by implying that they need constant approval from others.

Choice D is wrong because modeling competent care for the client does not necessarily help them to maintain their self-esteem.

It may even make them feel inadequate or dependent on the nurse.

A. Ask if the patient has started any new prescription or over-the-counter medications. B. Administer an anti-anxiety medication to subdue and sedate the patient. C. Place the patient in loose bilateral arm restraints. D. Tell the patient that the voices they are hearing are not real.

Correct Answer is A

Explanation

This is because the patient may be experiencing serotonin toxicity, a potentially life- threatening condition caused by excessive levels of serotonin in the brain. Paroxetine (Paxil) is a selective serotonin reuptake inhibitor (SSRI) that increases serotonin levels, and some other medications or supplements may interact with it and cause serotonin toxicity. Some of the symptoms of serotonin toxicity include agitation, increased sweating, and hallucinations.

Choice B is wrong because administering an anti-anxiety medication may worsen serotonin toxicity, especially if the medication is also an SSRI or another serotonergic agent.

Choice C is wrong because placing the patient in loose bilateral arm restraints may increase the risk of injury or agitation, and does not address the underlying cause of the symptoms.

Choice D is wrong because telling the patient that the voices they are hearing are not real may not be helpful or reassuring, and may also increase the patient’s distress or confusion.

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Which action should the nurse take after assessing a 2-day-old wound that has a crust along the edges, is red and appears slightly swollen?

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Naxlex Comprehensive Predictor Exams

Which nursing intervention would best assist a hospitalized client to maintain self-esteem?

Correct Answer is C

Explanation

A client taking paroxetine (Paxil) presents to the emergency room with agitation, increased sweating, and new auditory hallucinations. What is the priority action?

Correct Answer is A

Explanation

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