Multidimensional Care I (Rasmussen College) (MDC1)

The correct answer is: D. An older adult who has a hip fracture and is immobile.

Explanation

D. An older adult who has a hip fracture and is immobile

Older adults are at highest risk for skin breakdown due to age-related changes in skin integrity, reduced mobility, impaired circulation, and potential nutritional deficits. Prolonged immobility due to a hip fracture increases pressure over bony prominences (such as the sacrum and heels), leading to a higher risk of pressure injuries (pressure ulcers). Additionally, poor perfusion and delayed wound healing make the skin more vulnerable to breakdown.

Explanation of Incorrect Answers:

A. An adolescent who has a patella fracture and is in an immobilizer

Adolescents have better skin elasticity, circulation, and healing capacity, which significantly reduces the risk of skin breakdown. While the immobilizer restricts movement, it does not apply continuous pressure like a cast or prolonged immobility.

B. A young adult who has a femur fracture and is going to surgery in two hours

This client is likely mobile before surgery and will be repositioned frequently postoperatively. Surgical interventions are usually performed promptly, preventing prolonged immobility that could contribute to pressure injuries.

C. A middle-aged adult who has fractured his radius and has a cast

A fracture of the radius (forearm bone) does not significantly impact mobility. The client can still move, reposition, and walk freely, which helps prevent pressure injuries. While cast-related complications like pressure points can occur, they are less severe than immobility-related breakdown

Summary:

The greatest risk for skin breakdown occurs in older adults with prolonged immobility, as seen in the client with a hip fracture. Aging skin, decreased circulation, and continuous pressure on bony areas increase the risk of pressure ulcers. Clients with localized injuries (e.g., radius or patella fractures) or short-term immobility (e.g., preoperative femur fracture) are at lower risk.

The correct answer is: D. "Protein has amino acids that promote wound healing."

Explanation:

Protein is essential for tissue repair, immune function, and collagen synthesis, which are all crucial for wound healing, including the healing of pressure ulcers (bedsores). Protein provides amino acids, which are the building blocks of new tissue. Adequate protein intake helps prevent muscle wasting, supports immune function, and enhances wound healing.

Amino acids such as arginine and glutamine are essential for collagen formation, tissue regeneration, and immune support. Protein helps repair damaged tissue and speeds up the healing process. Clients with pressure ulcers often have increased protein needs due to tissue breakdown and the body's increased demand for repair.

Why the Other Options Are Incorrect:

A. "Because it is easy to digest." 

While some protein supplements may be easier to digest, this is not the main reason for giving protein supplements during wound healing. The key reason is its role in tissue repair and healing.

B. "If you don’t like it, you don’t have to take it." 

This response is inappropriate because it does not address the importance of protein in wound healing. If a client dislikes the supplement, the nurse should explore alternative protein sources rather than dismissing its importance.

C. "These supplements have nothing to do with your wound." 

This statement is factually incorrect. Protein is directly related to wound healing, and supplements are often prescribed for clients with wounds to ensure adequate protein intake for proper healing.

Summary:

Protein is essential for wound healing because it provides amino acids needed for tissue repair, immune function, and collagen formation. The best response is to educate the client about how protein aids in the healing process. If the client has concerns about the supplement, the nurse should discuss alternative protein sources rather than dismissing the need for protein intake.

The correct answer is: C. A positive rheumatoid factor.

Explanation 

C. A positive rheumatoid factor

Rheumatoid factor (RF) is an autoantibody that is commonly elevated in clients with rheumatoid arthritis (RA), particularly during a flare-up. A positive RF test indicates the presence of autoimmune activity, meaning the immune system is attacking the body's own tissues, contributing to joint inflammation and damage. While not all individuals with RA will have a positive RF, most do, especially in more severe or long-term cases.

Explanation of Incorrect Answers:

A. Decreased level of rheumatoid factor

During a flare-up, RF levels typically increase, not decrease. A flare-up signifies an increase in inflammatory activity, leading to higher RF levels.

B. A negative rheumatoid factor

A negative RF test does not rule out RA, as some people with the disease (seronegative RA) do not produce RF. However, the majority of RA patients do have a positive RF, especially during active disease phases.

D. Factor does not change

RF levels can fluctuate depending on disease activity. During flare-ups, RF levels often increase, reflecting the heightened autoimmune response. Thus, it is incorrect to say that RF levels do not change.

Summary:

A positive rheumatoid factor (RF) test is common in rheumatoid arthritis (RA), especially during a flare-up. It indicates the presence of autoimmune activity, which leads to joint inflammation and damage. While RF levels can fluctuate, they usually increase during periods of active disease.

The correct answer is: C. Stage IV pressure injury.

Explanation:

A Stage IV pressure injury is characterized by full-thickness skin and tissue loss with exposed bone, tendon, muscle, or fascia. In this case, the nurse observes bone and tendon at the base of the wound, which confirms that the injury has reached the deepest layers of tissue. Stage IV wounds often involve extensive necrosis, slough, or eschar and may also have tunneling or undermining. These injuries are serious and require advanced wound care, infection prevention, and pressure relief strategies.

Why the Other Options Are Incorrect:

A. A Stage II pressure injury 

Stage II pressure injuries involve partial-thickness skin loss with exposed dermis. The wound appears as a shallow, open ulcer with a pink or red wound bed but does not extend into deeper structures such as bone, tendon, or muscle. Since this client’s wound has exposed bone and tendon, it far exceeds the criteria for Stage II.

B. A Stage III pressure injury

Stage III pressure injuries involve full-thickness skin loss extending into the subcutaneous tissue but do not expose bone, tendon, or muscle. While Stage III wounds can have slough or tunneling, the presence of exposed bone and tendon in this case confirms that the injury has progressed beyond this stage.

D. A non-staging pressure injury 

A pressure injury is classified as unstageable only when its depth cannot be determined due to the presence of necrotic tissue (eschar) or slough obscuring the wound bed. In this scenario, since the bone and tendon are visible, the wound can be staged accurately as Stage IV.

Summary:

The presence of exposed bone and tendon in the wound confirms that it is a Stage IV pressure injury. Stage II and Stage III injuries do not extend this deep, and a non-staging injury applies only when the wound bed is obscured by necrotic tissue.

The correct answer is: B. Blood pressure of 175/90 mmHg.

Explanation

B. Blood pressure of 175/90 mmHg

Acute postoperative pain can trigger the sympathetic nervous system (SNS), leading to an increase in blood pressure (hypertension) and heart rate (tachycardia). This response occurs because pain stimulates the release of stress hormones like epinephrine and norepinephrine, which cause vasoconstriction and increased cardiac output, resulting in elevated blood pressure.

Explanation of Incorrect Answers:

A. Heart rate 60 beats/minute

Bradycardia (slow heart rate) is not a typical sign of acute pain. Instead, pain usually increases heart rate due to SNS activation. A heart rate of 60 beats per minute is normal and does not indicate significant pain.

C. Oxygen saturation of 97%

Pain does not directly affect oxygen saturation (SpO₂) unless there are respiratory complications such as hypoventilation or shallow breathing. An oxygen saturation of 97% is within the normal range, so this is not a strong indicator of pain.

D. Respirations of 10 breaths per minute

A low respiratory rate (bradypnea) is more likely due to opioid pain medications rather than pain itself. Severe pain usually causes increased respiratory rate (tachypnea) due to stress and discomfort, not a decrease in breathing.

Summary:

Pain stimulates the sympathetic nervous system, which increases blood pressure as part of the body's "fight or flight" response. Among the listed options, elevated blood pressure (175/90 mmHg) is the most likely sign of postoperative pain. Other vital signs, such as heart rate and oxygen saturation, do not strongly indicate pain in this scenario.

The correct answer is: D. Serosanguineous

Explanation:

Serosanguineous drainage is a mixture of serous fluid (clear, watery plasma) and blood, giving it a pink or light red color with a thin, watery consistency. It is common in the early stages of wound healing or after surgery and usually indicates normal healing. Since the wound is producing blood-tinged liquid that is dripping, this description best matches serosanguineous exudate.

Why the other choices are incorrect:

A. Purulent exudate

This is incorrect because purulent drainage is thick, yellow, green, or brown and indicates infection. The wound described in the question does not show signs of infection such as pus, foul odor, or increased redness.

B. Creamy pus

This is incorrect because pus is typically a sign of infection and is not described as blood-tinged. Pus is usually thick, white, yellow, or green and results from dead white blood cells and bacteria within the wound.

C. Serous

This is incorrect because serous drainage is clear or slightly yellow, watery, and does not contain blood. While serous fluid is normal in wound healing, it is not blood-tinged like the wound in the question.

Summary:

The correct documentation for a blood-tinged liquid draining from a surgical site is serosanguineous. This type of exudate is normal during healing and does not indicate infection. The other choices describe infected or clear fluid, which do not match the wound’s description.

The correct answer is: D. Fibromyalgia.

Explanation:

Fibromyalgia is not a complication of rheumatoid arthritis (RA). Although both conditions involve chronic pain and fatigue, they are distinct disorders. Fibromyalgia is a neurological condition that causes widespread musculoskeletal pain, tenderness, and fatigue but does not cause joint inflammation or damage, which are hallmark features of RA. While some individuals with RA may also develop fibromyalgia, it is not a direct complication of RA.

Why the other choices are correct complications of RA:

A. Paresthesia – This is a common complication of RA due to nerve compression from joint inflammation. Carpal tunnel syndrome is particularly common in RA, causing tingling, numbness, and burning sensations in the hands and fingers. Chronic inflammation in the joints can lead to nerve irritation, resulting in paresthesia.

B. Joint deformity – One of the most significant complications of RA is joint deformity, which occurs due to chronic inflammation, cartilage destruction, and bone erosion. Over time, RA leads to permanent joint damage and misalignment, commonly seen in the hands and fingers (e.g., swan-neck deformity and boutonnière deformity). This is a key characteristic of severe, untreated RA.

C. Dry eyes – Many RA patients develop secondary Sjögren’s syndrome, an autoimmune condition that leads to dry eyes and dry mouth due to inflammation of the tear and salivary glands. This condition affects mucous membranes and can cause gritty, irritated eyes.

Summary:

The correct answer is D. Fibromyalgia, as it is a separate condition rather than a direct complication of RA. Paresthesia (A), joint deformity (B), and dry eyes (C) are all recognized complications of RA due to nerve compression, chronic inflammation, and autoimmune involvement of mucous membranes.

The correct answer is: C. Natural passive.

Explanation

C. Natural passive

Passive immunity occurs when antibodies are transferred from one person to another rather than being produced by the recipient's own immune system. In the case of natural passive immunity, a mother passes preformed antibodies (IgG) to her fetus through the placenta. This provides temporary immunity to the newborn until their immune system matures and begins producing its own antibodies.

Explanation of Incorrect Answers:

A. Natural active

Natural active immunity occurs when a person is exposed to a pathogen naturally (such as through infection) and their immune system produces antibodies in response. This type of immunity is long-lasting because memory cells are formed. Example: A child who recovers from chickenpox develops natural active immunity.

B. Artificial active

Artificial active immunity occurs when a person is given a vaccine containing a weakened or inactivated form of a pathogen, stimulating their immune system to produce antibodies and memory cells. Example: Getting a measles, mumps, and rubella (MMR) vaccine.

D. Artificial passive

Artificial passive immunity occurs when a person receives pre-formed antibodies through an injection rather than producing them naturally. This provides immediate but short-term immunity. Example: A person exposed to rabies receives rabies immune globulin (RIG) to provide temporary protection.

Summary:

Natural passive immunity occurs when a mother passes antibodies to her fetus through the placenta, providing short-term immunity. Unlike active immunity, which requires the immune system to produce its own antibodies, passive immunity is temporary because no memory cells are formed.

The correct answer is: C. Request a medical interpreter.

Explanation:

When a client speaks only Spanish, the priority nursing intervention is to ensure clear and accurate communication by requesting a medical interpreter. Effective communication is essential for obtaining an accurate medical history, explaining procedures, verifying the reason for admission, and ensuring informed consent. Using a trained medical interpreter reduces the risk of miscommunication and ensures the client receives appropriate care. The interpreter must be qualified, as using family members or untrained staff can lead to misunderstandings or ethical concerns.

Why the Other Options Are Incorrect:

A. Calling the chaplain for support

While spiritual care is important for many patients, it does not address the immediate priority, which is establishing clear communication to assess and treat the client's medical condition. The chaplain may not be trained to interpret medical terminology accurately.

B. Verifying the reason for admission 

Although understanding the reason for admission is critical, it cannot be done effectively without proper communication. A language barrier can lead to misunderstandings, making it difficult for the nurse to gather accurate information. A medical interpreter must first be obtained to facilitate this process.

D. Giving the client a tour of the unit 

A unit tour is helpful for orientation but is not the priority when a language barrier exists. The first step should be ensuring effective communication so that the client's medical needs are understood and addressed appropriately.

Summary:

The priority nursing intervention when a client speaks only Spanish is to request a medical interpreter to ensure clear and accurate communication. This allows the nurse to obtain necessary medical information, provide instructions, and ensure patient safety. Other options, such as calling a chaplain, verifying admission details, or giving a tour, are secondary to establishing effective communication.