exam 3 - Thermoregulation Review, 29: Pain, 48: Skin Integrity and Wound Care
Assessment of pain
-Location -Onset/duration: when did it start? What precipitated it? Constant or intermittent? -Quality: burning, shooting, etc. -Intensity: numeric scale, faces pain scale, Wong Baker faces, verbal descriptor scale -Aggravating factors: What makes it worse? -Relieving factors: what makes it better?
Controlling pain is important to promoting wellness. Unrelieved pain has been associated with a. Prolonged stress response and a cascade of harmful effects system wide. b. Large tidal volumes and decreased lung capacity c. Decreased tumor growth and longevity d. Decreased carbohydrate, protein, and fat destruction
A. Prolonged stress response and a cascade of harmful effects system-wide
36. The nurse is caring for a patient who has suffered a stroke and has residual mobility problems. The patient is at risk for skin impairment. Which initial interventions should the nurse select to decrease this risk? a. Gentle cleaners and thorough drying of the skin b. Absorbent pads and garments c. Positioning with use of pillows d. Therapeutic beds and mattresses
ANS: A Assessment and skin hygiene are two initial defenses for preventing skin breakdown. Avoid soaps and hot water when cleansing the skin. Use gentle cleansers with nonionic surfactants. After bathing, make sure to dry the skin completely, and apply moisturizer to keep the epidermis well lubricated. Absorbent pads and garments are controversial and should be considered only when other alternatives have been exhausted. Positioning the patient reduces pressure and shearing force to the skin and is part of the plan of care but is not one of the initial components. Depending on the needs of the patient, a specialty bed may be needed, but again, this does not provide the initial defense for skin breakdown.
30. The nurse has collected the following assessment data: right heel with reddened area that does not blanch. What nursing diagnosis would the nurse assign? a. Ineffective tissue perfusion b. Risk for infection c. Imbalanced nutrition: less than body requirements d. Acute pain
ANS: A The area on the heel has experienced a decreased supply of blood and oxygen (tissue perfusion), which has resulted in tissue damage. The most appropriate nursing diagnosis with this information is Ineffective tissue perfusion. Risk for infection, Acute pain, and Imbalanced nutrition may be part of this patient's nursing diagnosis, but the data provided do not support this nursing diagnosis.
Chronic pain
Associated with disease process or persists after healing, lasts months, years, or even lifetime
An unresponsive older adult is admitted to the emergency department on a hot, humid day. The initial nursing assessment reveals hot, dry skin, a respiratory rate of 36 breaths/min, and a heart rate of 128 beats/min. What is the initial nursing action?
Remove the clothing.
On the day after surgery for insertion of a ventriculoperitoneal shunt to treat hydrocephalus, an infant's temperature increases to 103.0° F (39.4° C). The nurse immediately notifies the practitioner. What is the next nursing action?
Removing excess clothing from the infant
After surgery a client's fever does not respond to antipyretics. The health care provider prescribes that the client be placed on a hypothermia blanket. A response to hypothermia therapy that the nurse should prevent is:
Shivering
While assessing a newborn, the nurse notes that the skin is mottled. What should the nurse do first?
Warm the environment.
A nurse assesses the vital signs of a 50-year-old female client and documents the results. Which of the following are considered within normal range for this client? Select all that apply.
Oral temperature of 98.2° F Apical pulse of 88 beats per minute and regular Blood pressure of 116/78 mm Hg while in a sitting position
neuropathic pain
Pathology to somatosensory system Postherpetic neuralgia, diabetic neuropathy, phantom pain, trigeminal neuralgia, complex regional pain syndrome Shooting, burning, sharp
The nurse is reassessing a newborn who had an axillary temperature of 97° F (36° C) and was placed skin to skin with the mother. The newborn's axillary temperature is still 97° F (36° C) after 1 hour of skin-to-skin contact. Which intervention should the nurse implement next?
Placing the newborn under a radiant warmer in the nursery
Perception
Thalamus sends message to somatosensory cortex, frontal, parietal, et limbic to be interpreted based on past experiences, attitudes, beliefs, and meaning
A preterm neonate is receiving oxygen by way of an overhead hood. What should the nurse do to protect the infant under the oxygen hood?
Put a hat on the infant's head to avoid hypothermia
A preterm infant is receiving oxygen from an overhead hood. What nursing care is required while the infant is under the hood?
Putting a hat on the infant's head
Surgical Strategies
Regional anesthetic strategies: epidural steroid injections, joint injections, nerve blocks, implant of intrathecal analgesic delivery system Spinal cord stimulator Rhizotomy or neurectomy Joint replacement *ALL performed after all other pain control methods failed
Somatosensory
Cells, fibers, organs Receive, transmits, and interprets information related to pain
Individual risk factors
Communication barrier, cognitive impairment, developmental disability, mental health condition, injury associated with pain
A health care provider prescribes the application of a warm soak to an intravenous (IV) site that has infiltrated. What principle does the nurse determine is in operation when the application of local heat transfers temperature to the body?
Conduction
Transduction
Damage releases chemical mediators that activate nociceptors; membrane attachment --> Na channels open --> action potential initiated
A client's temperature is 100.4° F 12 hours after a spontaneous vaginal birth. What does the nurse suspect is the cause of the increased temperature?
Dehydration
What are the initial nursing actions after the birth of a preterm baby with an Apgar score of 6?
Drying the infant and placing the infant in a warm controlled environment
Soon after admission to the hospital with a head injury, a client's temperature increases to 102.2° F (39° C). The nurse considers that the client has sustained injury to what structure?
Hypothalamus
A client gives birth to a full-term male with an 8/9 Apgar score. What should the immediate nursing care of this newborn include?
Identifying the infant, assessing respirations, and keeping him warm
Osteoarthritis
Joint, cartilage becomes stiff and inelastic- tendon and ligament stretch et bone-on-bone causes pain *nociceptive, somatic pain
A nursing instructor provides education for the students on thermoregulation in the nursery. The students determine that in the healthy full-term neonate, heat production is accomplished by:
Metabolism of brown fat
somatic pain
originating from muscle, bone, joints, tendons, or blood vessels Sharp, localized
visceral pain
pain originating in the internal organs in the thorax, cranium, or abdomen Stretching, swelling, oxygen deprivation
Pharmacological Strategies
Multimodal regimen: combine drugs with different underlying indications Analgesics: non-opioid, opioids, adjunct analgesics Anticonvulsants et antidepressants Routes: oral whenever possible; IV, PCA, intrathecal, transdermal patch Placebo = NEVER!!! PCA: patient must be cognitive et physically able to self administer
5. The nurse is admitting an older patient from a nursing home. During the assessment, the nurse notes a shallow open ulcer without slough on the right heel of the patient. This pressure ulcer would be staged as stage a. I. b. II. c. III. d. IV.
ANS: B This would be a stage II pressure ulcer because it presents as partial-thickness skin loss involving epidermis, dermis, or both. The ulcer is superficial and presents clinically as an abrasion, blister, or shallow crater. Stage I is intact skin with nonblanchable redness over a bony prominence. With a Stage III pressure ulcer, subcutaneous fat may be visible, but bone, tendon, and muscles are not exposed. Stage IV involves full-thickness tissue loss with exposed bone, tendon, or muscle.
6. The nurse is updating the plan of care for a patient with a stage III pressure ulcer and a nursing diagnosis of Impaired skin integrity. Which of the following outcomes when met indicate progression toward goals? (Select all that apply.) a. Ask whether patient's expectations are being met. b. Prevent injury to the skin and tissues. c. Obtain the patient's perception of interventions. d. Reduce injury to the skin. e. Reduce injury to the underlying tissues. f. Restore skin integrity.
ANS: B, D, E, F Optimal outcomes are to prevent injury to skin and tissues, reduce injury to skin, reduce injury to underlying tissues, and restore skin integrity. Asking the patient's perceptions and whether expectations are being met allows one to obtain information regarding the experience, but these are not actual measurable outcomes.
29. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse assigns which of the following nursing diagnoses? a. Readiness for enhanced nutrition b. Impaired physical mobility c. Impaired skin integrity d. Chronic pain
ANS: C After the assessment is completed and the information that the patient has a stage IV pressure ulcer is gathered, a diagnosis of Impaired skin integrity is selected. Readiness for enhanced nutrition would be selected for an individual with an adequate diet that could be improved. Impaired physical mobility and Chronic pain, as well as the nutrition nursing diagnosis, could well be the nursing diagnoses selected for this patient, but current data in the question strongly support Impaired skin integrity.
11. The nurse is caring for a patient in the burn unit. The nurse recalls that this type of wound heals by a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention.
ANS: B A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater. A clean surgical incision is an example of a wound with little loss of tissue that heals by primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial- thickness repair are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved.
3. Which nursing observation would indicate that the patient was at risk for pressure ulcer formation? a. The patient ate two thirds of breakfast. b. The patient has fecal incontinence. c. The patient has a raised red rash on the right shin. d. The patient's capillary refill is less than 2 seconds.
ANS: B The presence and duration of moisture on the skin increase the risk of ulcer formation by making it susceptible to injury. Moisture can originate from wound drainage, excessive perspiration, and fecal or urinary incontinence. Bacteria and enzymes in the stool can enhance the opportunity for skin breakdown because the skin is moistened and softened, causing maceration. Eating a balanced diet is important for nutrition, but eating just two thirds of the meal does not indicate that the individual is at risk. A raised red rash on the leg again is a concern and can affect the integrity of the skin, but it is located on the shin, which is not a high-risk area for skin breakdown. Pressure can influence capillary refill, leading to skin breakdown, but this capillary response is within normal limits.
27. The nurse is completing a skin risk assessment utilizing the Braden scale. The patient has some sensory impairment and skin that is rarely moist, walks occasionally, and has slightly limited mobility, along with excellent intake of meals and no apparent problem with friction and shear. What would be the patient's Braden scale total score? a. 15 b. 17 c. 20 d. 23
ANS: C With use of the Braden scale, the patient receives 3 for slight sensory impairment, 4 for skin being rarely moist, 3 for walks occasionally, 3 for slightly limited mobility, 4 for intake of meals, and 4 for no problem with friction and shear. The total score is 20.
12. Which nursing observation would indicate that a wound healed by secondary intention? a. Minimal scar tissue b. Minimal loss of tissue function c. Permanent dark redness at site d. Scarring can be severe.
ANS: D A wound healing by secondary intention takes longer than one healing by primary intention. The wound is left open until it becomes filled with scar tissue. If the scarring is severe, permanent loss of function often occurs. Wounds that heal by primary intention heal quickly with minimal scarring. Scar tissue contains few pigmented cells and has a lighter color than normal skin.
A client with multiple myeloma who is receiving chemotherapy has a temperature of 102.2° F. The temperature was 99.2° F when it was taken six hours ago. A priority nursing intervention is to:
Administer the prescribed antipyretic and notify the primary health care provider
Transmission
Action potential moves along afferent nerves --> neurotransmitters allow action potential --> dorsal horn of spinal cord --> thalamus and midbrain
Physiological Consequences of pain
-Stress= increased cortisol catecholamines, glucagon -Unrelieved pain = respiratory effect = low tidal volumes = atelectasis et mechanical ventilation -Non-use of affected limb = atrophy of muscles and contracture of joint = further pain
A person sustains severe burns of the arms and is waiting for emergency services to arrive. A nurse bystander responds to the scene. Another bystander is getting ready to apply butter to the burns, stating that it will provide soothing relief. An appropriate response by the nurse is, "I wouldn't advise putting the butter on. Our focus should be on
... covering up the victim with one of those tablecloths.
Fibromyalgia
A type of mixed pain disorder characterized by widespread musculoskeletal pain, sleep disturbances, fatigue, cognitive et mood changes More common in women
8. The nurse is caring for a patient with a large abrasion from a motorcycle accident. The nurse recalls that if the wound is kept moist, it can resurface in _____ day(s). a. 4 b. 2 c. 1 d. 7
ANS: A A partial-thickness wound repair has three compartments: the inflammatory response, epithelial proliferation and migration, and re-establishment of the epidermal layers. Epithelial proliferation and migration start at all edges of the wound, allowing for quick resurfacing. Epithelial cells begin to migrate across the wound bed soon after the wound occurs. A wound left open to air resurfaces within 6 to 7 days, whereas a wound that is kept moist can resurface in 4 days. One or 2 days is too soon for this process to occur, moist or dry.
15. A patient has developed a decubitus ulcer. What laboratory data would be important to gather? a. Serum albumin b. Creatine kinase c. Vitamin E d. Potassium
ANS: A Normal wound healing requires proper nutrition. Serum proteins are biochemical indicators of malnutrition, and serum albumin is probably the most frequently measured of these parameters. The best measurement of nutritional status is prealbumin because it reflects not only what the patient has ingested, but also what the body has absorbed, digested, and metabolized. Measurement of creatine kinase helps in the diagnosis of myocardial infarcts and has no known role in wound healing. Potassium is a major electrolyte that helps to regulate metabolic activities, cardiac muscle contraction, skeletal and smooth muscle contraction, and transmission and conduction of nerve impulses. Vitamin E is a fat-soluble vitamin that prevents the oxidation of unsaturated fatty acids. It is believed to reduce the risk of coronary artery disease and cancer. Vitamin E has no known role in wound healing.
2. The nurse is caring for a patient who was involved in an automobile accident 2 weeks ago. The patient sustained a head injury and is unconscious. The nurse is able to identify that the major element involved in the development of a decubitus ulcer is a. Pressure. b. Resistance. c. Stress. d. Weight.
ANS: A Pressure is the main element that causes pressure ulcers. Three pressure-related factors contribute to pressure ulcer development: pressure intensity, pressure duration, and tissue tolerance. When the intensity of the pressure exerted on the capillary exceeds 12 to 32 mm Hg, this occludes the vessel, causing ischemic injury to the tissues it normally feeds. High pressure over a short time and low pressure over a long time cause skin breakdown. Resistance (the ability to remain unaltered by the damaging effect of something), stress (worry or anxiety), and weight (individuals of all sizes, shapes, and ages acquire skin breakdown) are not major causes of pressure ulcers.
39. The nurse is staffing a medical-surgical unit that is assigned most of the patients with pressure ulcers. The nurse has become competent in the care of pressure wounds and recognizes that a staged pressure ulcer that does not require a dressing is stage a. I. b. II. c. III. d. IV.
ANS: A Stage I intact pressure ulcers that resolve slowly without epidermal loss over 7 to 14 days do not require a dressing. This allows visual inspection and monitoring. A transparent dressing could be used to protect the patient from shear but cannot be used in the presence of excessive moisture. A composite film, hydrocolloid, or hydrogel can be utilized on a clean stage II. A hydrocolloid, hydrogel covered with foam, calcium alginate, gauze, and growth factors can be utilized with a clean stage III. Hydrogel, calcium alginate, gauze, and growth factors can be utilized with a clean stage IV. An unstageable wound cover with eschar should utilize a dressing of adherent film or gauze with an ordered solution of enzymes. In rare cases when eschar is dry and intact, no dressing is used, but this is an unstaged ulcer.
26. The nurse is completing an assessment of the skin's integrity, which includes a. Pressure points. b. All pulses. c. Breath sounds. d. Bowel sounds.
ANS: A The nurse continually assesses the skin for signs of ulcer development. Assessment of tissue pressure damage includes visual and tactile inspection of the skin. Observe pressure points such as bony prominences and areas next to treatments such as a binasal cannula and the nares. Assessment of pulses, breath sounds, and bowel sounds is part of a head-to-toe assessment and could influence the function of the body and ultimately skin integrity; however, this assessment is not a specific part of a skin assessment.
1. The nurse is caring for a patient with a stage II pressure ulcer and as the coordinator of care understands the need for a multidisciplinary approach. The nurse evaluates the need for several consults. Which of the following should always be included in the consults? (Select all that apply.) a. Registered dietitian b. Enterostomal and wound care nurse c. Physical therapist d. Case management personnel e. Chaplain f. Pharmacist
ANS: A, B, C, D A registered dietitian is useful in working with the nurse to determine a meal plan that will support wound healing. An enterostomal or wound care nurse specializes in caring for the needs of the patient with wounds. Physical therapy is concerned about the mobility of the patient and can assist an immobile patient to progress toward mobility and decrease the risk for pressure ulcers. Pressure ulcers take a long time to heal and usually require continued therapy in the home. Case management personnel are useful in obtaining care for the patient outside the home. If the patient has a spiritual need, the chaplain can assist. If the patient has a need associated with medications, the pharmacist can assist. However, chaplains and pharmacists usually are not part of the wound care multidisciplinary team, unless a special need arises.
5. The nurse is caring for a patient who will have both a large abdominal bandage and an abdominal binder. The nurse's responsibilities and activities before applying the bandage and binder include which of the following? (Select all that apply.) a. Inspecting the skin for abrasions and edema b. Covering exposed wounds c. Assessing condition of current dressings d. Assessing the skin at underlying areas for circulatory impairment e. Marking the sites of all abrasions f. Cleansing the area with hydrogen peroxide
ANS: A, B, C, D Before applying a bandage or a binder, the nurse has several responsibilities. The nurse would need to inspect the skin for abrasions, edema, and discoloration or exposed wound edges. The nurse also is responsible for covering exposed wounds or open abrasions with a sterile dressing and assessing the condition of underlying dressings and changing if soiled, as well as assessing the skin of underlying areas that will be distal to the bandage. This checks for signs of circulatory impairment, so that a comparison can be made after bandages are applied. Marking the sites of all abrasions is not necessary. Although it is important for the skin to be clean, and even though it may need to be cleaned with a noncytotoxic cleanser, cleansing with hydrogen peroxide can interfere with wound healing.
3. The nurse is completing a skin assessment on a medical-surgical patient. Which nursing assessment questions should be included in a skin integrity assessment? (Select all that apply.) a. "Can you easily change your position?" b. "Do you have sensitivity to heat or cold?" c. "How often do you need to use the toilet?" d. "Is movement painful?" e. "What medications do you take?" f. "Have you ever fallen?"
ANS: A, B, C, D Changing positions is important for decreasing the pressure associated with long periods of time in the same position. If the patient is able to feel heat or cold and is mobile, he can protect himself by withdrawing from the source. Knowing toileting habits and any potential for incontinence is important because urine and feces in contact with the skin for long periods can increase skin breakdown. Knowing whether the patient has problems with mobility such as pain will alert the nurse to any potential for decreased movement and increased risk for skin breakdown. Medications and falling are safety risk questions.
2. The nurse is caring for a patient with wound healing by tertiary intention. Which factors does the nurse recognize as influencing wound healing? (Select all that apply.) a. Nutrition b. Evisceration c. Tissue perfusion d. Infection e. Hemorrhage f. Age
ANS: A, C, D, F Normal wound healing requires proper nutrition. Oxygen and the ability to provide adequate amounts of oxygenated blood are critical for wound healing. Wound infection prolongs the inflammatory phase, delays collagen synthesis, prevents epithelialization, and decreases the production of proinflammatory cytokines, which leads to additional tissue destruction. As patients age, all aspects of wound healing are delayed. Hemorrhage and evisceration are complications of wound healing.
32. The medical-surgical acute care patient has received a nursing diagnosis of Impaired skin integrity. The nurse consults a a. Respiratory therapist. b. Registered dietitian. c. Chaplain. d. Case manager.
ANS: B Assessment and a plan for the patient to optimize the diet are essential. Adequate calories, protein, vitamins, and minerals promote wound healing. The nurse is the coordinator of care, and collaborating with the dietitian would result in planning the best meals for the patient. The respiratory therapist can be consulted when a patient has issues with the respiratory system. Case management can be consulted when the patient has a discharge need. A chaplain can be consulted when the patient has a spiritual need.
22. The nurse is caring for a patient who has a wound drain with a collection device. The nurse notices that the collection device has a sudden decrease in drainage. What would be the nurse's next best step? a. Remove the drain; a drain is no longer needed. b. Call the physician; a blockage is present in the tubing. c. Call the charge nurse to look at the drain. d. As long as the evacuator is compressed, do nothing.
ANS: B Because a drainage system needs to be patent, look for drainage flow through the tubing, as well as around the tubing. A sudden decrease in drainage through the tubing may indicate a blocked drain, and you will need to notify the physician. The health care provider determines the need for drain removal and removes drains. Notifying the charge nurse, although important for communication, is not the next step in providing care for this patient. The evacuator may be compressed when a blockage is present.
21. The nurse is caring for a patient on the medical-surgical unit with a wound that has a drain and a dressing that needs changing. Which of these actions should the nurse take first? a. Don sterile gloves. b. Provide analgesic medications as ordered. c. Avoid accidentally removing the drain. d. Gather supplies.
ANS: B Because removal of dressings is painful, if often helps to give an analgesic at least 30 minutes before exposing a wound and changing the dressing. The next sequence of events includes gathering supplies for the dressing change, donning gloves, and avoiding the accidental removal of the drain during the procedure.
35. The home health nurse is caring for a patient with impaired skin integrity in the home. The nurse is reviewing dressing changes with the caregiver. Which intervention assists in managing the expenses associated with long-term wound care? a. Sterile technique b. Clean dressings and no touch technique c. Double bagging of contaminated dressings d. Ability of the caregiver
ANS: B Clean dressings as opposed to sterile dressings are recommended for home use. This recommendation is in keeping with principles regarding nosocomial infection, and it takes into account the expense of sterile dressings and the dexterity required for application. The caregiver can use the same no touch technique for dressing changes that is used for changing surface dressings without touching the wound or the surface that might come in contact with the wound. Double bagging is required for the disposal of contaminated dressings. The dressings go in a bag, which is fastened and then placed in the household trash. The ability of the caregiver certainly is a component of the success of home treatment, but it does not influence the cost of supplies.
40. The nurse is caring for a patient with a wound. The patient appears anxious as the nurse is preparing to change the dressing. What should the nurse do to decrease the patient's anxiety? a. Tell the patient to close his eyes. b. Explain the procedure. c. Turn on the television. d. Ask the family to leave the room.
ANS: B Explaining the procedure educates the patient regarding the dressing change and involves him in his care, thereby allowing the patient some control in decreasing anxiety. Telling the patient to close his eyes and turning on the television are distractions that do not usually decrease a patient's anxiety. If the family is a support system, asking support systems to leave the room can actually increase a patient's anxiety.
42. The nurse is caring for a patient after an open abdominal aortic aneurysm repair. The nurse requests an abdominal binder and carefully applies the binder. What is the best explanation for the nurse to use when teaching the patient the reason for the binder? a. The binder creates pressure over the abdomen. b. The binder supports the abdomen. c. The binder reduces edema at the surgical site. d. The binder secures the dressing in place.
ANS: B The patient has a large abdominal incision. This incision will need support, and an abdominal binder will support this wound, especially during movement, as well as during deep breathing and coughing. A binder can be used to create pressure over a body part, for example, over an artery after it has been punctured. A binder can be used to prevent edema, for example, in an extremity but is not used to reduce edema at a surgical site. A binder can be used to secure dressings such as elastic webbing applied around a leg after vein stripping.
4. The nurse is caring for a patient with potential skin breakdown. Which components would the nurse include in the skin assessment? (Select all that apply.) a. Mobility b. Hyperemia c. Induration d. Blanching e. Temperature of skin f. Nutritional status
ANS: B, C, D, E Assessment of the skin includes both visual and tactile inspection. Assess for hyperemia and abnormal reactive hyperemia (when the skin turns red after an obstruction of blood flow returns and vasodilatation causes the tissue to turn red). Assess for indurated (hardened) areas on the skin and palpate reddened areas for blanching. Changes in temperature can indicate changes in blood flow to that area of the skin. Mobility and nutritional status are certainly part of the overall assessment for pressure ulcer risk but are not part of the actual skin assessment
33. The nurse is caring for a patient with a stage II pressure ulcer and has assigned a nursing diagnosis of Risk for infection. The patient is unconscious and bedridden. The nurse is completing the plan of care and is writing goals for the patient. What is the best goal for this patient? a. The patient's family will demonstrate specific care of the wound site. b. The patient will state what to look for with regard to an infection. c. The patient will remain free of an increase in temperature and of odorous or purulent drainage from the wound. d. The patient's family members will wash their hands when visiting the patient.
ANS: C Because the patient has an open wound and the skin is no longer intact to protect the tissue, the patient is at increased risk for infection. The nurse will be assessing the patient for signs and symptoms of infection, including an increase in temperature, an increase in white count, and odorous and purulent drainage from the wound. The patient is unconscious and is unable to communicate the signs and symptoms of infection; also, this is an intervention, not a goal for this diagnosis. It is important for the patient's family to be able to demonstrate how to care for the wound and wash their hands, but these statements are interventions, not goals or outcomes for this nursing diagnosis.
41. The nurse is cleansing a wound site. As the nurse administers the procedure, what intervention should be included? a. Allowing the solution to flow from the most contaminated to the least contaminated b. Scrubbing vigorously when applying solutions to the skin c. Cleansing in a direction from the least contaminated area d. Utilizing clean gauge and clean gloves to cleanse a site
ANS: C Cleanse surgical or traumatic wounds by applying noncytotoxic solution with sterile gauze or irrigations. Cleanse in a direction from the least contaminated area. Use gentle friction when applying solutions to the skin, and allow irrigation to flow from the least to the most contaminated area.
34. The nurse is caring for a postpartum patient. The patient has an episiotomy after experiencing birth. The physician has ordered heat to treat this condition, and the nurse is providing this treatment. This patient is at risk for a. Infection. b. Impaired skin integrity. c. Trauma. d. Imbalanced nutrition.
ANS: C Heat causes vasodilatation and is used to improve blood flow to an injured body part. The application of heat incorrectly when the treatment is too hot, or is applied too long or to the wrong place, can result in a burn for the patient and risk for additional trauma. The skin already has impaired integrity owing to the surgical procedure, and because of this has been at risk for infection since the surgical procedure was performed. This patient is of childbearing age and has had a child. Additional needs for nutrition are present during pregnancy and breastfeeding, but this is an established nursing diagnosis. Data are insufficient to support the nursing diagnosis of Imbalanced nutrition.
43. The nurse is caring for a postoperative medial meniscus repair of the right knee. To assist with pain management following the procedure, which intervention should the nurse implement? a. Monitor vital signs every 15 minutes. b. Apply brace to right knee. c. Elevate right knee and apply ice. d. Check pulses in right foot.
ANS: C Ice assists in preventing edema formation, controlling bleeding, and anesthetizing the body part. Elevation assists in preventing edema, which in turn can cause pain. Monitoring vital signs every 15 minutes is routine postoperative care and includes a pain assessment but in itself is not an intervention that decreases pain. Applying a brace provides support and decreases the opportunity for additional trauma, which in turn assists in the healing process. Checking the pulses is important to monitor the circulation of the extremity but in itself is not a pain management intervention.
31. The nurse is caring for a patient with a stage III pressure ulcer. The nurse has assigned a nursing diagnosis of Risk for infection. Which intervention would be most important for this patient? a. Teach the family how to manage the odor associated with the wound. b. Discuss with the family how to prepare for care of the patient in the home. c. Encourage thorough handwashing of all individuals caring for the patient. d. Encourage increased quantities of carbohydrates and fats.
ANS: C The number one way to decrease the risk of infection by breaking the chain of infection is to wash hands. Encouraging fluid and food intake helps with overall wellness and wound healing, especially protein, but an increase in carbohydrates and fats does not relate to the risk of infection. If the patient will be discharged before the wound is healed, the family will certainly need education on how to care for the patient. Teaching the family how to manage the odor associated with a wound is certainly important, but these interventions do not directly relate to the risk of infection and breaking the chain of the infectious process.
37. The nurse is caring for a patient who is at risk for skin impairment. The patient is able to sit up in a chair. The nurse includes this intervention in the plan of care. How long should the nurse schedule the patient to sit in the chair? a. At least 3 hours b. Not longer than 30 minutes c. Less than 2 hours d. As long as the patient remains comfortable
ANS: C When patients are able to sit up in a chair, make sure to limit the amount of time to 2 hours or less. The chair sitting time should be individualized. In the sitting position, pressure on the ischial tuberosities is greater than in a supine position. Utilize foam, gel, or an air cushion to distribute weight. Longer than 2 hours can increase the chance of ischemia.
38. The nurse is caring for a patient who is immobile and is at risk for skin impairment. The plan of care includes turning the patient. What is the best method for repositioning the patient? a. Obtain assistance and use the drawsheet to place the patient into the new position. b. Place the patient in a 30-degree supine position. c. Utilize a transfer sliding board and assistance to slide the patient into the new position. d. Elevate the head of the bed 45 degrees.
ANS: C When repositioning the patient, obtain assistance and utilize a transfer sliding board under the patient's body to prevent dragging the patient on bed sheets and placing the patient at high risk for shearing and friction injuries. The patient should be placed in a 30-degree lateral position, not supine position. The head of the bed should be elevated less than 30 degrees to prevent pressure ulcer development from shearing forces.
44. The patient has been provided a nursing diagnosis of Risk for skin impairment and has a 15 on the Braden scale upon admission. The nurse has implemented interventions for this nursing diagnosis. Upon reassessment, which Braden score would be the best sign that the risk for skin breakdown is decreasing? a. 12 b. 13 c. 20 d. 23
ANS: D The Braden scale is composed of six subscales: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. The total score ranges from 6 to 23, and a lower total score indicates a higher risk for pressure ulcer development. The cutoff score for onset of pressure ulcer risk with the Braden scale in the general adult population is 18. The best sign is a perfect score of 23.
6. The nurse is completing a skin assessment on a patient with darkly pigmented skin. Which of the following would be used first to assist in staging an ulcer on this patient? a. Cotton-tipped applicator b. Disposable measuring tape c. Sterile gloves d. Halogen light
ANS: D When assessing a patient with darkly pigmented skin, proper lighting is essential to accurately complete the first step in assessment—inspection—and the whole assessment process. Natural light or a halogen light is recommended. Fluorescent light sources can produce blue tones on darkly pigmented skin and can interfere with an accurate assessment. Other items that could possibly be used during the assessment include gloves for infection control, a disposable measuring device to measure the size of the wound, and a cotton-tipped applicator to measure the depth of the wound, but these items not the first item used.
Pain is PROTECTIVE :
Alerts the brain to potential or actual body harm
Complex Regional Pain Syndrome (CRPS)
Neuralgia that affects one of the limbs following injury/trauma to that limb Prolonged, excessive pain, mild to dramatic changes in skin temp, color, or edema. More common in women
Post-stroke pain
Occurs immediately after a CVA or weeks to months to affected area Pins and needles
During the assessment of a preterm neonate the nurse determines that the infant is experiencing hypothermia. What should the nurse do?
Rewarm gradually
Other risk factors of pain
Sex, race, ethnicity Women have higher chronic pain and lower thresholds of pain Income/education, geographic locale Culture/religion are barriers to reporting pain
What is the nurse's initial action immediately after assisting with a precipitous birth in the triage area of the emergency department?
Warming the newborn
Pain
an unpleasant sensory and emotional experience associated with actual or potential tissue damage
Older adults
increased pain with age r/t musculoskeletal disorders, surgical, falls/trauma, misconception regarding med administration is confusion and respiratory suppression
Gait Control Theory
Dorsal horn of spinal cord act as gates in which pain signals compete with signals of other stimuli for passage through gate and transmission to brain. -small fibers open, lg. close -high sensory input can close gate (distractions) -"pieces of pain", the more pieces the more pain
Immediately after birth, a newborn is dried before being placed in skin-to-skin contact with the mother. What type of heat loss does this intervention prevent?
Evaporation
Nociceptors
Free nerve endings in skin, muscle, joints, arteries, and the viscera that respond to chemical, mechanical, and thermal stimuli and transmit pain information
A nurse must continually assess a preterm infant's temperature and provide appropriate nursing care because, unlike the full-term infant, the preterm infant:
Has a limited supply of brown fat available to provide heat
Post-herpetic neuralgia
Pain after resolution of the seeable varicella zoster virus reoccurrence. Increased incidences with advanced age
phantom pain
Pain felt in a body part that is no longer there
Margo McCaffery
Pain is highly subjective. Pain is whatever the patient says it is, existing whenever the patient says it does.
Infants/children
Painful illness or procedures combined with lack of cognition to report/describe pain
Acute pain
Short-term, self-limiting, often predictable trajectory; stops after injury heals
A client has been diagnosed with hyperthyroidism. The nurse expects the client to exhibit which clinical manifestations? Select all that apply
Nervousness Increased appetite
Trigeminal Neuralgia
Neuropathic pain resulting from cranial nerve V damage- burning, shock-like pain to the face seconds to minutes and severely debilitating
A 6-year-old boy is sent to the school nurse on a snowy below-freezing day because he arrived without a coat, wearing shorts, a T-shirt, and sandals. What is the first nursing intervention?
Checking the child for frostbite
The nurse has initiated an intravenous antibiotic on a client with hyperpyrexia and diminished urine output. The nurse concludes that the probable cause of the diminished urine output is:
A compensatory response to fever
After surgery for insertion of a coronary artery bypass graft (CABG), a client develops a temperature of 102° F (38.8° C). What priority concern related to elevated temperatures does a nurse consider when notifying the health care provider about the client's temperature?
A fever increases the cardiac output
Alan is a 30-year-old male admitted to the hospital with acute pancreatitis. He is in acute pain described as a 10/10, which is localized to the abdomen, periumbilical area, and some radiation to his back. The abdomen is grossly distended so it is difficult to assess. He is restless and agitated, with elevated pulse and blood pressure. An appropriate pain management plan of care may include A. IV Dilaudid q 4 hours PRN, hydrocodone 5/500 PO q 6 hours PRN, and acetaminophen. B. Norco 5/500 q 4 hours PO and Benadryl 25 mg PO q 6 hours. C. Phenergan 25 mg IM q 6 hours. D. Tylenol 325 mg q 6 hours.
A. IV Dilaudid q4h PRN, Norco 5/500mg q6h PRN, and acetaminophen Oral route whenever feasible, long standing pain = long acting analgesic for baseline pain and fast-onset medication for breakthrough pain
A 19-year old male has sustained a transaction of C-7 in an MVA reddening his quadriplegic. He describes his pain as burning, sharp, and shooting. This is characteristic of A. Neuropathic pain B. Ghost pain C. Mixed pain syndrome D. Nociceptive pain
A. Neuropathic pain Damage to the brain, spinal cord, peripheral nerves resulting in burning or shooting sensation
20. A patient presents to the emergency department with a laceration of the right forearm caused by a fall. After determining that the patient is stable, the next best step is to a. Inspect the wound for bleeding. b. Inspect the wound for foreign bodies. c. Determine the size of the wound. d. Determine the need for a tetanus antitoxin injection.
ANS: A After determining that a patient's condition is stable, inspect the wound for bleeding. An abrasion will have limited bleeding, a laceration can bleed more profusely, and a puncture wound bleeds in relation to the size and depth of the wound. Address any bleeding issues. Inspect the wound for foreign bodies; traumatic wounds are dirty and may need to be addressed. Determine the size of the wound. A large open wound may expose bone or tissue and be protected, or the wound may need suturing. When the wound is caused by a dirty penetrating object, determine the need for a tetanus vaccination.
17. The nurse is caring for a patient with a healing stage III pressure ulcer. Upon entering the room, the nurse notices an odor and observes a purulent discharge, along with increased redness at the wound site. What is the next best step for the nurse? a. Complete the head-to-toe assessment, and include current treatment, vital signs, and laboratory results. b. Notify the charge nurse about the change in status and the potential for infection. c. Notify the physician by utilizing Situation, Background, Assessment, and Recommendation (SBAR). d. Notify the wound care nurse about the change in status and the potential for infection.
ANS: A The patient is showing signs and symptoms associated with infection in the wound. It is serious and needs treatment but is not a life-threatening emergency, where care is needed immediately or the patient will suffer long-term consequences. The nurse should complete the assessment; gather all data such as current treatment modalities, medications, vital signs including temperature, and laboratory results such as the most recent complete blood count or white cell count. The nurse can then notify the physician and receive treatment orders for the patient. It is important to notify the charge nurse and consult the wound nurse on the patient's status and on any new orders.
14. Which of these findings if seen in a postoperative patient should the nurse associate with dehiscence? a. Complaint by patient that something has given way b. Protrusion of visceral organs through a wound opening c. Chronic drainage of fluid through the incision site d. Drainage that is odorous and purulent
ANS: A occurs is when a wound fails to heal properly and the layers of skin and tissue separate. It involves abdominal surgical wounds and occurs after a sudden strain such as coughing, vomiting, or sitting up in bed. Patients often report feeling as though something has given way. Evisceration is seen when vital organs protrude through a wound opening. A fistula is an abnormal passage between two organs or between an organ and the outside of the body that can be characterized by chronic drainage of fluid. Infection is characterized by drainage that is odorous and purulent.
23. The nurse is caring for a patient who has a stage IV pressure ulcer awaiting plastic surgery consultation. Which of the following specialty beds would be most appropriate? a. Standard mattress b. Nonpowered redistribution air mattress c. Low-air-loss therapy unit d. Lateral rotation
ANS: B A low-air-loss therapy unit is utilized for stage IV pressure ulcers and when prevention or treatment of skin breakdown is needed. If the patient has a stage III or stage IV ulcer or a postoperative myocutaneous flap, the low-air-loss therapy unit would be an appropriate selection. A static air mattress or nonpowered redistribution is utilized for the patient at high risk for skin breakdown. A standard mattress is utilized for an individual who does not have actual or potential altered or impair skin integrity. Lateral rotation is used for treatment and prevention of pulmonary complications associated with mobility.
28. The nurse is caring for a medical-surgical patient. To decrease the risk of pressure ulcers and encourage the patient's willingness and ability to increase mobility, which intervention is most important for the nurse to complete? a. Encourage the patient to sit up in the chair. b. Provide analgesic medication as ordered. c. Explain the risks of immobility to the patient. d. Turn the patient every 3 hours while in bed.
ANS: B Maintaining adequate pain control and patient comfort increases the patient's willingness and ability to increase mobility, which in turn reduces pressure ulcer risks. It is good to encourage a patient to move about but even better if the patient actually sits up in the chair. Explaining the risk of immobility is important for the patient because it may impact the patient's willingness but not his or her ability. Turning the patient is important for decreasing pressure ulcers but needs to be done every 2 hours, and again does not influence the patient's ability to increase mobility.
1. The nurse is working on a medical-surgical unit that has been participating in a research project associated with pressure ulcers. The nurse recognizes that the risk factors that predispose a patient to pressure ulcer development include a. A diet low in calories and fat. b. Alteration in level of consciousness. c. Shortness of breath. d. Muscular pain.
ANS: B Patients who are confused or disoriented or who have changing levels of consciousness are unable to protect themselves. The patient may feel the pressure but may not understand what to do to relieve the discomfort or to communicate that he or she is feeling discomfort. Impaired sensory perception, impaired mobility, shear, friction, and moisture are other predisposing factors. Shortness of breath, muscular pain, and a diet low in calories and fat are not included among the predisposing factors.
25. The nurse is caring for a patient with a healing stage III pressure ulcer. The wound is clean and granulating. Which of the following orders would the nurse question? a. Use a low-air-loss therapy unit. b. Consult a dietitian. c. Irrigate with hydrogen peroxide. d. Utilize hydrogel dressing.
ANS: C Clean pressure ulcers with noncytotoxic cleansers such as normal saline, which will not kill fibroblasts and healing tissue. Cytotoxic cleansers such as Dakin's solution, acetic acid, povidone-iodine, and hydrogen peroxide can hinder the healing process and should not be utilized on clean granulating wounds. Consulting a dietitian for the nutritional needs of the patient, utilizing a low-air-loss therapy unit to decrease pressure, and applying hydrogel dressings to provide a moist environment for healing are all orders that would be appropriate.
24. The nurse is caring for a patient with a pressure ulcer on the left hip. The ulcer is black. The nurse recognizes that the next step in caring for this patient includes a. Monitoring of the wound. b. Irrigation of the wound. c. Débridement of the wound. d. Management of drainage.
ANS: C Débridement is the removal of nonviable necrotic tissue. Removal of necrotic tissue is necessary to rid the ulcer of a source of infection, to enable visualization of the wound bed, and to provide a clean base for healing. A wound will not move through the phases of healing if the wound is infected. Irrigating the wound with noncytotoxic cleaners will not damage or kill fibroblasts and healing tissue and will help to keep the wound clean once débrided. When treating a pressure ulcer, it is important to monitor and reassess the wound at least every 8 hours. Management of drainage will help keep the wound clean.
9. The nurse is caring for a patient who is experiencing a full-thickness repair. The nurse would expect to see which of the following in this type of repair? a. Eschar b. Slough c. Granulation d. Purulent drainage
ANS: C Granulation tissue is red, moist tissue composed of new blood vessels, the presence of which indicates progression toward healing. Soft yellow or white tissue is characteristic of slough—a substance that needs to be removed for the wound to heal. Black or brown necrotic tissue is called eschar, which also needs to be removed for a wound to heal. Purulent drainage is indicative of an infection and will need to be resolved for the wound to heal.
16. Which of the following would be the most important piece of assessment data to gather with regard to wound healing? a. Muscular strength assessment b. Sleep assessment c. Pulse oximetry assessment d. Sensation assessment
ANS: C Oxygen fuels the cellular functions essential to the healing process; the ability to perfuse tissues with adequate amounts of oxygenated blood is critical in wound healing. Blood flow through the pulmonary capillaries provides red blood cells for oxygen attachment. Oxygen diffuses from the alveoli into the pulmonary blood; most of the oxygen attaches to hemoglobin molecules within the red blood cells. Red blood cells carry oxygenated hemoglobin molecules through the left side of the heart and out to the peripheral capillaries, where the oxygen detaches, depending on the needs of the tissues. Pulse oximetry measures the oxygen saturation of blood. Assessment of muscular strength and sensation, although useful for fitness and mobility testing, does not provide any data with regard to wound healing. Sleep, although important for rest and for integration of learning and restoration of cognitive function, does not provide any data with regard to wound healing.
7. The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of a. Primary intention. b. Partial-thickness wound repair. c. Full-thickness wound repair. d. Tertiary intention.
ANS: C Pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do not regenerate, hence the need for full-thickness repair. The full-thickness repair has three phases: inflammatory, proliferative, and remodeling. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges approximated. Wound closure is delayed until risk of infection is resolved.
18. The nurse is collaborating with the dietitian about a patient with a stage III pressure ulcer. After the collaboration, the nurse orders a meal plan that includes increased a. Fat. b. Carbohydrates. c. Protein. d. Vitamin E.
ANS: C Protein needs are especially increased in supporting the activity of wound healing. The physiological processes of wound healing depend on the availability of protein, vitamins (especially A and C), and the trace minerals of zinc and copper. A balanced diet of fat and carbohydrates, along with protein, vitamins, and minerals, is needed in any diet. Wound healing does not require increased amounts of fats or carbohydrates. Vitamin E has no known role in wound healing.
19. The nurse is completing an assessment on an individual who has a stage IV pressure ulcer. The wound is odorous, and a drain is currently in place. The nurse determines that the patient is experiencing issues with self-concept when the patient states which of the following? a. "I think I will be ready to go home early next week." b. "I am so weak and tired, I want to feel better." c. "I am ready for my bath and linen change as soon as possible." d. "I am hoping there will be something good for dinner tonight."
ANS: C The patient's psychological response to any wound is part of the nurse's assessment. Body image changes can influence self-concept. 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 wound is odorous, and a drain is in place. The patient who is asking for a bath and change in linens gives you a clue that he or she may be concerned about the smell in the room. The patient 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.
4. The wound care nurse visits a patient in the long-term care unit. The nurse is monitoring a patient with a stage III pressure ulcer. The wound seems to be healing, and healthy tissue is observed. How would the nurse stage this ulcer? a. Stage I pressure ulcer b. Healing stage II pressure ulcer c. Healing stage III pressure ulcer d. Stage III pressure ulcer
ANS: C When a pressure ulcer has been staged and is beginning to heal, the ulcer keeps the same stage and is labeled with the words "healing stage." Once an ulcer has been staged, the stage endures even as the ulcer heals. This ulcer was labeled a stage III, it cannot return to a previous stage such as stage I or II. This ulcer is healing, so it is no longer labeled a stage III.
10. The nurse is caring for a patient who has experienced a laparoscopic appendectomy. The nurse recalls that this type of wound heals by a. Tertiary intention. b. Secondary intention. c. Partial-thickness repair. d. Primary intention.
ANS: D A clean surgical incision is an example of a wound with little loss of tissue that heals with primary intention. The skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges are approximated. Wound closure is delayed until the risk of infection is resolved. A wound involving loss of tissue such as a burn or a pressure ulcer or laceration heals by secondary intention. The wound is left open until it becomes filled with scar tissue. It takes longer for a wound to heal by secondary intention; thus the chance of infection is greater.
13. The nurse is caring for a patient who has experienced a total hysterectomy. Which nursing observation would indicate that the patient was experiencing a complication of wound healing? a. The incision site has started to itch. b. The incision site is approximated. c. The patient has pain at the incision site. d. The incision has a mass, bluish in color.
ANS: D A hematoma is a localized collection of blood underneath the tissues. It appears as swelling, change in color, sensation, or warmth or a mass that often takes on a bluish discoloration. A hematoma near a major artery or vein is dangerous because it can put pressure on the vein or artery and obstruct blood flow. Itching of an incision site can be associated with clipping of hair, dressings, or possibly the healing process. Incisions should be approximated with edges together. After surgery, when nerves in the skin and tissues have been traumatized by the surgical procedure, it is expected that the patient would experience pain.
Modulation
Activation of brainstem releases endorphins, enkephalins, serotonin and dynophin to stimulate relapse of endogenous opioids to inhibit further pain impulse
Nociceptive pain
Alerts the brain to potential or actual tissue harm The brain may filter or block pain information or change perception
Jan is a 70-year-old retired nurse who is interested in nondrug, mind-body therapies, self-management, and alternative strategies to deal with joint discomfort from rheumatoid arthritis. What options should you consider in her plan of care considering her expressed wishes? a. Stationary exercise bicycle, free weights, and spinning class b. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy c. Chamomile tea and IcyHot gel d. Acupuncture and attending church services
B. Mind-body therapies such as music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation techniques, and pet therapy Enhancing the mind's capacity to affect body functions
Understanding classifications of pain helps nurses develop a plan of care. A 62-year old male has fallen while trimming tree branches sustaining tissue injury. He describes his condition as an aching, throbbing back. This is characteristic of A. Neuropathic pain B. Nociceptive pain C. Chronic pain D. Mixed pain syndrome
B. Nociceptive pain Normal function of the somatosensory system: eudynic= throbbing, aching, cramping
Nonpharmacologic Pain Management
Body-based modalities: massage, heat/cold, acupuncture, imagery, relaxation, breathing, & meditation *Compliments other strategies, but do not replace Proper body alignment- achieved through positioning Thermal measures- application of localized heat/cold Mind-body therapies- music therapy, distraction techniques, meditation, prayer, hypnosis, guided imagery, relaxation, and pet therapy Biologically based- herbs, vitamins, reiki, et tai chi
An elderly Chinese woman is interested in biologically based therapies to relieve osteoarthritis pain (OA). You are preparing a plan of care for her OA. Options most conducive to her expressed wishes may include a. Pilates, breathing exercises, and aloe vera. b. Guided imagery, relaxation breathing, and meditation. c. Herbs, vitamins, and tai chi. d. Alternating ice and heat to relieve pain and inflammation.
C. Herbs, vitamins, and tai chi Biological based measures
A client with hypothermia is brought to the emergency department. What treatment does the nurse anticipate?
Core rewarming with warm fluids
Psychosocial Consequences of pain
Fear, anger, depression, anxiety, decreased ability to maintain relationships, work, and keep up with normal activities
Which is a characteristic of the glands that secrete a thick substance in response to emotional stimulation and become odoriferous due to bacterial action?
Grow in conjunction with axillary hair follicles
While assessing a term infant a few hours after birth, the nurse finds a body temperature of 95.5° F. What does the nurse do in this situation?
Keep the infant in a double-walled incubator for a few hours
A parent of a preterm infant asks a nurse in the neonatal intensive care unit why the baby is in a bed with a radiant warmer. The nurse explains that preterm infants are at increased risk for hypothermia because they
Lack the subcutaneous fat that usually provides insulation
The nurse is measuring the body temperature of four neonates born at term in a pediatric health setting. Which neonate has normal body temperature?
Neonate 3 The normal body temperature of term neonates is in the range of 36.5° to 37.5° C. Therefore, a body temperature of 37.1° C is a normal finding. The body temperatures of 35.5° C and 36.0° C in neonates 1 and 2 indicate hypothermia. The body temperature of 38.5° C in neonate 4 indicates hyperthermia
mixed pain syndromes
Painful conditions and syndromes that are not easily categorized and thought to be unique with multiple underlying and poorly understood mechanisms Fibromyalgia, low back pain, myofascial pain
A nurse is caring for a mother and neonate. What is the priority nursing action to prevent heat loss in the neonate immediately after birth?
Putting the naked newborn on the mother's skin and covering the infant with a blanket
