VSIM Josephine Morrow POST quiz
The nurse is evaluating Josephine Morrow's understanding of the plan of care to promote wound healing. The patient demonstrates understanding when she selects which of the following foods for her meal? (Select all that apply.)
Chicken breast, Orange, Broccoli, Milk Rationale:Foods that are high in protein and vitamin C will promote wound healing. Chicken breasts and milk are high in protein. Oranges and broccoli are high in vitamin C. Cereals may be high in sugar and would not be helpful for wound healing. White rice has neither protein nor vitamin C. Apples are high in fiber, but this is not a food choice that would promote wound healing.
The nurse recognizes that Josephine Morrow is at a high risk for the development of Choose Answer.. due to Choose Answer..
Correct Response:Blank-1. deep vein thrombosis (DVT) Blank-2. decreased mobility Rationale:Patients with decreased mobility are at a high risk for the development of a deep vein thrombosis (DVT) due to the venous stasis that occurs with prolonged immobility; the DVT could progress to a pulmonary embolus (PE). For patients at a high risk for the development of a DVT, the nurse would anticipate a prescription or order for DVT prophylaxis, either sequential-compression devices (SCDs) or low-dose anticoagulation with subcutaneous enoxaparin or an oral antiplatelet medication such as clopidogrel. The patient is not at risk of developing arterial insufficiency, heart failure, or cyanosis as a result of the decreased immobility. Peripheral edema, hyperpigmentation on both legs, and loneliness are not causative factors of the development of a DVT.
The nurse recognizes that Josephine Morrow's limited mobility can have adverse effects on the skin. What other information would the nurse need to gather to establish priorities for the plan of care? (Select all that apply.)
Fall risk, Nutritional status, Smoking history, Hygiene status/practices, Circulation status Rationale:To establish priorities for the plan of care, the nurse would need to gather information about fall risk, nutritional status, smoking history, hygiene practices, and circulation status. Risk factors that can lead to skin breakdown and pressure injuries include poor circulation, poor hygiene, infrequent position changes, dermatitis, infection, and traumatic wounds. The nurse should use a skin assessment tool to assess the patient for risk for injury development, scoring six factors in the matrix to assess the patient's risk for breakdown: sensory perception, moisture, activity, mobility, nutrition, and friction and shear. A smoking history is needed because smoking can contribute to decreased oxygen available to the wounds, and oxygen is essential for healing. A patient's family history does not have a direct correlation to a patient's limited mobility and subsequent risks for skin breakdown.
The nurse is inspecting Josephine Morrow's skin. To which areas should the nurse pay close attention while performing a physical assessment? (Select all that apply.)
Under the breasts, Groin, Arms and legs, Sacrum Rationale:Because Josephine Morrow is obese, the nurse should pay particular attention to the areas that are prone to skin breakdown and fungal skin infections: under the breasts as well as folds of skin in the groin, arms, and legs. Patients who are obese frequently perspire, and the skin in these areas is prone to friction. In addition, patients who are obese require assistance in movement and repositioning, increasing the likelihood of skin breakdown, so the sacrum is important to assess. The nurse can also assess the hair, scalp, eyes, ears, and surface of the abdomen, but these areas are not ones likely to be of major concern
The nurse is providing education to Josephine Morrow on how to prevent additional venous stasis ulcers from developing. Which statement(s) would be appropriate to include in the teaching plan? (Select all that apply.)
Wear support stockings to help prevent ulcers and heal existing ones.', 'Watch for signs and symptoms of new ulcers.' Rationale:It is appropriate during education for the nurse to encourage Josephine Morrow to wear support stockings to prevent ulcers by promoting venous circulation. It is important for the nurse to teach the patient how to recognize signs and symptoms of new ulcers and to seek care from the health care provider if these are observed. The nurse would not recommend activities that require aerobic activity and physical contact, which would cause additional wounds to arise; the patient should participate in light to moderate activity, such as swimming or walking, to promote circulation. Instructing the patient to wear nonskid footwear with support soles and safety rail instillation would be beneficial in preventing falls. Stable blood sugar levels do contribute to optimal wound healing; however, Ms. Morrow does not have a diagnosis of diabetes, and there has been no indication that her blood sugars have been elevated, so they do not need to be monitored.
In developing goals collaboratively with the patient, the nurse would write the following short-term priority goal in the care plan: The patient will Choose Answer.. by Choose Answer..
name three foods that contribute to wound healing, the date of discharge Rationale:The goal meets the SMART guidelines: it is specific, measurable, appropriate, realistic, and timely for Josephine Morrow's diagnosis and current health problem. Chronic obstructive pulmonary disease (COPD) does contribute to Ms. Morrow's overall health status; however, this is not the cause of her recent admission to the hospital. Walking independently is not as high a priority as promoting wound healing. Being discharged home independently may or may not be a feasible goal for Ms. Morrow given her current health status. The time frames of 3 days from now, 1 month from now, and 6 months from now are too far in the future; the patient needs to know this information upon discharge so wound healing can continue after discharge.
