The nurse is completing an assessment on a patient who has a Stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. Which statement by the patient indicates issues with self-concept?
a. "I am so weak and tired. I want to feel better."
b. "I am thinking I will be ready to go home early next week."
c. "I am ready for my bath and linen change right now since this is awful."
d. "I am hoping there will be something good for dinner tonight."
ANS: C
Body image changes can influence self-concept. The wound is odorous, and a drain is in place. The patient who is asking for a bath and change in linens and states that this is awful gives you a clue that he or she may be concerned about the smell in the room. Factors that affect the patient's perception of the wound include the presence of scars, drains, odor from drainage, and temporary or permanent prosthetic devices. The patient's stating that he or she wants to feel better, talking about going home, and caring about what is for dinner could be interpreted as positive statements that indicate progress along the health journey.
You might also like to view...
Which of these electronic databases is the most relevant and frequently used source for nursing literature?
a. MEDLINE b. CINAHL c. Cochrane Collaboration d. National Guideline Clearinghouse
The nurse is providing care to an older adult patient diagnosed with severe multiple sclerosis (MS). The patient has the urge to urinate but is often incontinent because of an inability to navigate to the toilet
Which type of incontinence is the patient experiencing? 1) Stress 2) Overflow 3) Urge 4) Functional
During a mock training session, student nurses are taught the acronym "PASS" to be followed during a fire. What does "A" stand for?
A) Activate the pin on the fire extinguisher. B) Aim at the base of the fire, near the edge. C) Call for assistance with the fire extinguisher. D) Aim and squeeze the handles together.
A premenopausal client diagnosed with breast cancer will be receiving hormonal therapy. The nurse anticipates that the physician will request which medication for this client?
A. Anastrazole (Arimdex) B. Fulvestrant (Faslodex) C. Leuprolide (Lupron) D. Trastuzumab (Herceptin)