A hospital patient has a large, superficial wound on her elbow that was the result of shearing action when she was moved up in her bed
The patient's husband mentions that the wound looks infected and irritated because the wound bed is completely red. Which of the following responses would be inappropriate?
A)
"Even though it is red, it doesn't mean that the wound is infected."
B)
"The red areas show that there is enough circulation to facilitate healing."
C)
"Those are fresh blood vessels that are a sign of healthy healing."
D)
"A thin sheet of blood clotting is actually desirable and not a sign that your wife's wound is infected."
Ans:
D
Feedback:
Granulation tissue indicates sufficient circulation and angiogenesis associated with healthy wound healing. Granulation tissue consists of new blood vessels, not clotted cellular components.
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A home care nurse visits a 68-year-old man who lives alone and has no family and finds him tearful and withdrawn. The patient has been managing well at home up until this time. The nurse would take which of the following actions?
A) Reassess the patient's psychosocial status and make the necessary referrals. B) Have the patient volunteer in the community for social contact. C) Arrange for him to be reassessed by his physician. D) Encourage joining a group that plays cards every week.
A patient with acute mania undresses in the day room and dances about. Select the best intervention
a. Quietly ask the patient, "Are you embarrassed? Don't you think you should put your clothes on?" b. Let the patient stay in the day room. Move other patients to a different area. c. Cover the patient with a blanket and walk with the patient to a quiet room. d. Tell the patient firmly, "Stop dancing and put on your clothing.".
When ketones accumulate in the blood, clients with diabetes are prone to developing a form of metabolic acidosis known as __________
Fill in the blank(s) with correct word
A nurse who serves on an infection control committee is assessing the adequacy of environmental controls against infection. This nurse would examine which of the following as the first line of defense in medical asepsis?
1. isolation or barrier procedures 2. hand-washing techniques 3. nature of detergent used on unit 4. type of ventilation system