The Nursing Process
The Nursing Process ( 5 Questions)
A nurse is conducting a problem-focused assessment on a client who has a pressure ulcer on their sacrum. Which of the following data should the nurse collect? (Select all that apply.).
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Choice A :
The size, depth, and color of the wound are important indicators of the stage and severity of the pressure ulcer. Measuring these parameters can help monitor the healing process and guide the appropriate treatment.
Choice B:
The presence of drainage, odor, or infection can signal complications or poor healing of the pressure ulcer. Drainage can indicate excessive moisture or exudate that can impair wound healing. Odor can suggest bacterial colonization or necrotic tissue. Infection can cause systemic symptoms such as fever, malaise, or leukocytosis.
Choice C:
The type and frequency of dressing changes are essential components of pressure ulcer management. Dressings should be chosen based on the characteristics of the wound, such as the amount of exudate, the presence of necrotic tissue, or the need for debridement. Dressings should be changed as often as necessary to maintain a moist but not wet environment for wound healing.
Choice D :
The client's pain level and preferred analgesics are important data to collect because pressure ulcers can cause significant discomfort and affect the quality of life of the client. Pain can also interfere with wound healing by increasing stress and inflammation. Analgesics should be prescribed according to the client's needs and preferences, taking into account the potential side effects and interactions.
Choice E :
The client's nutritional status and fluid intake are not part of a problem-focused assessment on a client who has a pressure ulcer on their sacrum. These data are relevant for a comprehensive assessment that includes all aspects of the client's health and well-being. However, a problem-focused assessment is more narrow and specific to the presenting problem or issue. Therefore, choice E is not correct.