Test #7: Metabolism & Tissue Integrity

While the nurse is performing a nutritional assessment, the patient states, "I am on a vegan diet. I have been a vegan for 10 years." What is the best response by the nurse?

"Can you tell me about the foods you eat along with any other supplements you take?

After instructing a mother about nutrition for a preschool-age child, which statement by the mother indicates correct understanding of the topic?

"I know that lifelong food habits are developed during this stage of life."

A 30-year-old patient newly diagnosed with type 2 diabetes states to the nurse, "If glucose is so important, then I think as long as my blood sugar is high I must be doing well." What is the most appropriate response by the nurse?

"I understand how you are thinking; however, a high glucose level does not mean that there is more fuel available for your body's cells. Because you have diabetes, your body cells can't use the excess glucose."

The nurse is caring for a patient who states, "I have been smoking two packs of cigarettes a day for 20 years, and now my nurse practitioner wants me to take vitamins. Do you think I need to take vitamins?" What is the most appropriate response by the nurse?

"Smokers use vitamin C faster than do nonsmokers, and this is linked to iron deficiency. You can either eat more foods containing vitamin C and iron or take dietary supplements."

An adult client is fully able to detect and respond to pain and discomfort. He has no incontinence or mobility limitations. He is of normal weight and consumes a nutritious diet. The client has no problem with rubbing, friction, or shear. What is the Braden score for this client?

23

Which of the following clients does the nurse recognize as being at greatest risk for pressure ulcers?

A middle-aged adult with quadriplegia

The nurse obtains a swab culture from a chronic wound and understands that this may have limited findings. Why is the information obtained from a swab culture of a wound limited?

A positive culture does not necessarily indicate infection because chronic wounds are often colonized by bacteria.

The nurse admitting a new patient to the medical-surgical unit is conducting a dietary history. What information should the nurse include? Select all that apply.

Basic eating habits, Food preferences, Attitude toward food, Cultural dietary restrictions

Which class of nutrients is the body's primary source of energy?

Carbohydrates

For a patient with Risk for Imbalanced Nutrition: Less Than Body Requirements related to Impaired Swallowing, which nursing interventions are appropriate? Select all that apply.

Check inside the mouth for pocketing of food after eating., Keep the head of the bed elevated for 30 to 45 minutes after feeding.

The nurse is assessing the client with a wound that is considered chronic. The client asks the nurse to explain the difference between chronic and acute wounds. Which of the following would best describe the primary difference between chronic and acute?

Chronic wounds exceed the typical healing time, but acute wounds heal readily.

The nurse completes the nutrition assessment for a 14-year-old female with a body mass index (BMI) of 15. Which physical assessment finding would cause the nurse to suspect an eating disorder?

Cold intolerance

The nurse is reviewing the client's surgical report and notes that the client has a history of evisceration. The nurse researches the differences between dehiscence and evisceration. Which of the following describes the difference between dehiscence and evisceration?

Dehiscence involves a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.

Which instructions should the nurse give to the older adult patient experiencing constipation? Select all that apply.

Drink at least eight glasses of water or fluid per day., Consume whole grains and fresh greens., Include both soluble and insoluble fibers in the diet.

The nurse is providing care to the client who is 2 days status post cerebrovascular accident with residual decreased left-sided mobility. During the assessment, the nurse discovers a stage 1 pressure area on the client's left heel. What is the initial treatment for this pressure ulcer?

Elevation of the left heel off the bed to relieve the pressure

An elderly female, adequately nourished, was admitted to the skilled nursing facility 3 months ago. Since then, she has had a significant weight loss and has become weak. Her appetite and activity level are reduced, and she has lost interest in interacting with other patients. What would the nurse suspect the reason for her condition to be?

Frail elderly syndrome

A client has an area of nonblanchable erythema on his coccyx. The nurse has determined this to be a stage 1 pressure ulcer. What would be the most important treatment for this client?

Frequent turning schedule

The home health nurse learns that an elderly client isn't able to get to the grocery store. She doesn't have much food in her home, and eats and drinks little. Most of her time is spent sitting in her chair watching television, often not realizing that she has bladder leakage. Which nursing actions would she implement to reduce the risk of developing a pressure ulcer? Select all that apply.

Help her to get out of the chair every 2 hours., Change her clothing frequently., Encourage her to wear incontinence products.

Select the process(es) that occur(s) during the inflammatory phase of wound healing. Select all that apply.

Hemostasis, Inflammation

The nurse is preparing to perform wound care for the client that has a stage 2 pressure ulcer on their right buttock. The ulcer is covered with dry, yellow slough that tightly adheres to the wound. What is the best treatment the nurse could recommend for treating this wound?

Hydrocolloid dressing changed as needed

A 52-year-old man has a body mass index of 28.9, and his weight exceeds the ideal body weight for height by 23%. Which nursing diagnosis should the nurse identify for this patient?

Imbalanced Nutrition: More Than Body Requirements

Which patient is most likely experiencing positive nitrogen balance? A patient admitted:

In the sixth month of a healthy pregnancy

The nurse recognizes that pressure ulcers are directly caused by which of the following conditions at the site?

Interrupted blood flow

The nurse is preparing to provide wound care to a client with many open wounds. Which of the following actions would be the most appropriate method for dressing changes of multiple open wounds that require treatment?

Irrigate wounds from the least contaminated area to the most contaminated area.

In a patient with type 1 diabetes mellitus admitted with hyperglycemia, fats are being broken down for energy. Which alternative fuel does the breakdown of fats produce?

Ketones

The nurse is caring for a patient with a significant history of hypertension and cardiovascular disease. The nurse would be most interested in the findings of which laboratory results?

Lipoproteins, such as low-density and high-density lipoproteins (LDLs and HDLs)

Where in the body is glucose stored? Select all that apply.

Liver, Skeletal Muscles

Which laboratory test result most accurately reflects a patient's nutritional status?

Prealbumin

The nurse is assessing the client's wound and notes that the wound bed shows granulation. What phase of wound healing is described by the nurse's note?

Proliferative

Which nutrient deficiency increases the risk for tissue breakdown?

Protein

The nurse documents that the new wound has serosanguineous drainage. How is serosanguineous described?

Red, watery, clear

The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client:

Remains free of foot wounds

Which nutritional goal is appropriate for a patient newly diagnosed with hypertension? The patient will:

Restrict use of sodium

The nurse is developing a plan of care for a client who was injured in a motor vehicle accident yesterday. The client is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator. Which of the following would be an appropriate nursing diagnosis for him at this time?

Risk for Impaired Skin Integrity related to immobility

The nurse in the emergency department admits a client with a gunshot wound to the lower abdomen accompanied by heavy bleeding. What type of drainage does the nurse expect to see on the dressing?

Sanguineous

A client underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is:

Secondary intention healing

For an elderly client who is experiencing chronic nausea and weight loss, which laboratory result would the nurse recognize as being most consistent with a diagnosis of Imbalanced Nutrition: Less Than Body Requirements?

Serum albumin of 3.2 g/dL

The nurse is assessing the client who presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it?

Stage 2

While addressing a community group, the nurse explains the importance of replacing saturated fats in the diet with mono- and polyunsaturated fats. The nurse emphasizes that doing so greatly reduces the risk of which complication?

Stroke

The nurse learns in report that the assigned client has a stage 3 pressure ulcer. What type of tissue does the nurse expect to visualize in the wound? Select all that apply.

Subcutaneous tissue, Dermis, Fascia

The nurse is preparing to provide care to the client who has a contaminated right hip wound that requires dressing changes twice daily. The surgeon informs the nurse that when the wound "heals a little more" he will suture it closed. The nurse recognizes that the surgeon is using which form of wound healing?

Tertiary intention

The nurse is developing a teaching plan for a client that has a surgical incision that has been left open. Which of the following points would the nurse make?

The client will have more scar tissue formation than there would be for a wound closed at surgery.

The nurse is reviewing the history and physical records of the newly admitted client in the wound care clinic. There is a notation that states there is an absence of the stratum corneum. Which of the following explains why this is a concern?

The stratum corneum protects the body against the entry of pathogens.

The registered nurse (RN) on a medical-surgical unit is making assignments. Which tasks would the RN delegate to the licensed practical nurse (LPN)? Select all that apply.

Tube feeding, Fingerstick blood glucose, Nutritional history

A client hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. There is a pressure area on the client's coccyx measuring 5 x 3 cm. The area is covered with 100% eschar. What would the nurse identify this as?

Unstageable pressure ulcer

The pediatric nurse is preparing a teaching plan about vitamins for parents of school-age children. What vital information will the nurse include in the plan? Select all that apply

Water-soluble vitamins are needed for cellular metabolism., Vitamins are necessary for preventing particular deficiency diseases, Because the body does not make vitamins, they must be supplied by the foods we eat.

Which food item provides the body with no usable glucose?

Wheat Germ

A patient who underwent surgery 24 hours ago is prescribed a clear liquid diet. The patient asks for something to drink. Which item may the nurse provide for the patient?

White grape juice

To promote wound healing, the nurse is teaching a patient about choosing foods containing protein. The nurse will evaluate that learning has occurred if the patient recognizes which foods are incomplete proteins that should be consumed with a complementary protein? Select all that apply.

Whole grain rice, Legumes

The nurse is reviewing a wound care nurse's narrative note that states there is a fistula in the lower abdominal wall as a result of a poorly healing surgical wound. What is a common cause of a fistula?

Abscess formation from infection