Multidimensional Care I (Rasmussen College) (MDC1)

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: A. A client who has just had surgery.

Explanation

A. A client who has just had surgery.

A client who has recently undergone surgery is at the highest risk of compromised immunity because surgery causes physical stress, inflammation, and potential breaks in the skin barrier. The immune system is weakened due to the body's response to trauma, anesthesia, blood loss, and potential exposure to pathogens in the hospital environment. Additionally, post-surgical clients may have drains, catheters, or wounds that provide entry points for infections. The combination of these factors makes this client highly susceptible to infections.

Explanation of Incorrect Answers:

B. A client with extreme anxiety.

Although extreme anxiety can cause physiological stress and temporarily elevate cortisol levels, which may have a mild suppressive effect on the immune system, it does not compromise immunity as significantly as surgery. Unlike physical trauma, anxiety does not create direct vulnerabilities such as open wounds or a weakened inflammatory response

C. A client who is awaiting surgery.

A client who is awaiting surgery may experience stress, but their immune system is not yet compromised unless they have an existing condition that affects immunity. The highest risk occurs after the surgery, when the body is actively healing and more vulnerable to infections.

D. A client who just delivered a baby.

While childbirth does involve physical stress, most healthy postpartum clients recover quickly, and their immune systems function normally. However, postpartum women may have a slightly increased risk of infection due to perineal tears, cesarean incisions, or exposure to hospital-acquired infections, but this risk is lower than that of a post-surgical client who has undergone major invasive procedures.

Summary:

The client at the highest risk for compromised immunity is the post-surgical client because surgery weakens the immune system, increases inflammation, and creates entry points for infection. While anxiety, awaiting surgery, and childbirth can have some impact on immunity, none of these pose as high a risk as recent surgery.

The correct answer is: B. A client that recently traveled and developed a fever with a cough

Explanation:

Airborne precautions are used for diseases that are transmitted through tiny droplets or particles that can remain suspended in the air. These infections require negative pressure rooms and N95 respirators for healthcare providers. A client who has recently traveled and presents with fever and cough may have tuberculosis (TB), COVID-19, measles, or another airborne-transmissible illness, requiring airborne precautions until a definitive diagnosis is made.

Travel history increases the risk of exposure to airborne infections such as tuberculosis, measles, or SARS-CoV-2 (COVID-19). Fever and cough are respiratory symptoms, which may indicate an airborne-transmissible disease. Until the cause is confirmed, the client should be placed under airborne precautions to prevent potential transmission.

Why the Other Options Are Incorrect:

A. A client with an unknown skin infection 

Skin infections are typically spread by contact, not through airborne transmission. If the infection is draining or suspected to be highly contagious (e.g., MRSA, scabies, or chickenpox), contact or droplet precautions might be needed instead.

C. A high school wrestling champion with a rash 

Skin rashes in wrestlers are commonly due to fungal infections (ringworm) or bacterial infections (impetigo, MRSA), which require contact precautions, not airborne isolation. Airborne precautions are not needed unless the rash is consistent with chickenpox (varicella) or measles, which is not specified.

D. A client with heart palpitations 

Heart palpitations are not infectious and do not require isolation. There is no evidence of an airborne disease in this case.

Summary:

A client with recent travel history, fever, and cough should be placed under airborne precautions until further testing confirms or rules out diseases like tuberculosis, measles, or COVID-19. The other options involve non-airborne conditions that require different or no isolation measures.

The correct answer is: A. Assess the client’s support system.

Explanation 

A. Assess the client’s support system

When a client receives a new diagnosis of HIV, they may experience shock, fear, anxiety, and distress. The best initial nursing intervention is to assess the client’s support system, which includes family, friends, and community resources. Emotional and social support plays a crucial role in helping the client cope with their diagnosis. Understanding their available support helps the nurse determine what resources and interventions may be most beneficial for the client.

Explanation of Incorrect Answers:

B. Call the hospital clergy to speak with the client

While spiritual support can be helpful, it is not the first priority. The nurse should first assess what type of support the client prefers before making assumptions about their spiritual needs. Some clients may not be religious or may prefer to talk to someone else, such as a mental health professional or a close friend.

C. Explain the legal requirement to tell sex partners

It is important for the client to understand their responsibility in informing past and current sex partners about their HIV status, but this is not the first intervention. The priority is to address the client’s emotional distress and provide support before introducing legal and ethical obligations. Once the client is more emotionally stable, discussions about partner notification can take place in a nonjudgmental and supportive manner

D. Offer to tell the family for the client

The client has the right to privacy and confidentiality, and disclosing their diagnosis without their consent is a violation of HIPAA (Health Insurance Portability and Accountability Act). The nurse should support and empower the client in deciding how and when to tell their family.

Summary:

The best intervention is to assess the client’s support system, as emotional and social support are crucial for coping with an HIV diagnosis. While spiritual support, legal requirements, and family disclosure are important considerations, they should not be addressed before assessing the client’s emotional needs and preferences.

The correct answer is: C. Raynaud's phenomenon.

Explanation

C. Raynaud's phenomenon

Raynaud’s phenomenon is often the first symptom of systemic sclerosis (scleroderma). It occurs due to vasospasms of the small blood vessels in response to cold or stress, leading to color changes in the fingers and toes (white, blue, and red phases). This occurs before skin thickening or joint pain and can be an early warning sign of the disease.

Explanation of Incorrect Answers:

A. Joint pain

While joint pain can occur in scleroderma due to fibrosis and inflammation, it is not typically the first symptom. It develops later as the disease progresses.

B. Intense wrinkles

Scleroderma actually causes skin tightening, not wrinkles. The skin becomes thick and tight, especially on the face and hands, giving a mask-like appearance, but this happens later in the disease.

D. Tachycardia

Tachycardia is not an early symptom of scleroderma. Cardiopulmonary complications can occur later, but Raynaud’s phenomenon typically presents first.

Summary:

The first symptom of systemic sclerosis (scleroderma) is Raynaud’s phenomenon, which causes vasospasms and color changes in the fingers and toes. Joint pain, skin tightening, and cardiac symptoms develop later in the disease course.

The correct answer is: A. Polyuria

Explanation:

Inflammation is the body's natural immune response to injury, infection, or irritation. The classic signs of inflammation are heat, redness (erythema), swelling (edema), pain, and loss of function.

A. Polyuria (Excessive Urination)

This is not an expected finding in a client with inflammation. Polyuria is usually associated with conditions such as diabetes mellitus, diabetes insipidus, kidney disorders, or excessive fluid intake, rather than the inflammatory response. Inflammation does not directly cause increased urination.

Why Other Options are Incorrect

B. Edema (Swelling)

This is an expected finding in inflammation. Edema occurs due to increased capillary permeability, allowing fluids to leak into the surrounding tissues, leading to swelling in the affected area.

C. Heat (Increased Temperature in the Affected Area)

This is an expected finding in inflammation. Heat occurs due to increased blood flow (vasodilation) to the inflamed area, which brings white blood cells and immune factors to fight off infection or heal tissue damage.

D. Erythema (Redness)

This is an expected finding in inflammation. Erythema occurs due to increased blood flow to the affected area, making the skin appear red and warm. This is a direct result of vasodilation in response to inflammatory signals.

Summary:

The only answer that is not an expected assessment finding in a client with inflammation is polyuria. Edema, heat, and erythema are all classic signs of inflammation, resulting from increased blood flow, capillary permeability, and immune activity.

The correct answer is: B. Deep vein thrombosis (DVT)

Explanation:

A client with systemic sclerosis (scleroderma) who has been bedridden for two weeks and now presents with a hot, red, and painful leg is showing classic signs of deep vein thrombosis (DVT). Prolonged immobility increases the risk of venous stasis, which can lead to clot formation in the deep veins, most commonly in the legs.

Why This Answer Is Correct:

B. Deep vein thrombosis (DVT) 

Key signs of DVT include swelling, warmth, redness, and pain in one leg. Bedrest and immobility increase the risk of DVT due to venous stasis and hypercoagulability. Scleroderma can also contribute to vascular issues, making blood clot formation more likely. DVT is a medical emergency because the clot could dislodge and cause a pulmonary embolism (PE).

Why the Other Options Are Incorrect:

A. Amputation 

The symptoms described do not indicate the need for amputation at this stage. Amputation is considered only in cases of severe tissue necrosis, gangrene, or irreversible ischemia, which are not mentioned in the scenario.

C. Internal bleeding

Internal bleeding usually presents with hypotension, pallor, bruising, dizziness, or abdominal pain, rather than a localized hot, red, and painful leg. There is no mention of trauma or anticoagulant use, which are common causes of internal bleeding.

D. Kidney failure 

Kidney failure presents with symptoms like fluid retention, decreased urine output, electrolyte imbalances, and high blood pressure. A hot, red, painful leg is not a typical sign of kidney failure.

Summary:

A client with scleroderma, prolonged immobility, and new-onset leg redness, warmth, and pain is at high risk for deep vein thrombosis (DVT). This is a medical emergency due to the risk of pulmonary embolism. Other options (amputation, internal bleeding, kidney failure) do not fit the clinical presentation. The nurse should immediately notify the healthcare provider, ensure bedrest, and anticipate diagnostic tests like a Doppler ultrasound.

The correct answer is:

A. Reduced inflammation

D. Decreased pain

E. Increased quality of life

Explanation:

A. Reduced inflammation: This is correct because the primary aim of medications for rheumatoid arthritis (RA) is to reduce inflammation. RA is an autoimmune disease that causes joint inflammation, and medications like disease-modifying antirheumatic drugs (DMARDs) and biologics are specifically designed to control and reduce this inflammation. Reducing inflammation helps to prevent joint damage and can control disease progression.

D. Decreased pain: This is correct because one of the benefits of reducing inflammation in RA is a reduction in pain. As the inflammation decreases, joint pain generally lessens, leading to better comfort for the patient. Pain relief is an expected outcome when inflammation is managed effectively through medication.

E. Increased quality of life: This is correct because managing inflammation and pain can significantly improve the quality of life for individuals with RA. Medications help individuals maintain their daily functions, preventing disability and promoting overall well-being. With less pain and improved joint function, people with RA can lead more active and fulfilling lives.

Why the other choices are incorrect:

B. Increased range of motion: This is incorrect because while medications may help improve joint function by reducing inflammation and preventing damage, medications themselves do not directly increase the range of motion. Increased range of motion is a result of reduced inflammation and proper physical therapy, not solely from the medication.

C. Cure the disease: This is incorrect because there is currently no cure for rheumatoid arthritis. Although medications can help manage symptoms and slow the progression of the disease, they cannot cure it. The goal of treatment is to control the disease and minimize its effects, not to eliminate it entirely.

Summary:

The primary expected outcomes of medications for rheumatoid arthritis include reduced inflammation, decreased pain, and improved quality of life. While medications can improve symptoms and slow disease progression, they do not cure the disease, and increasing the range of motion is a secondary effect that may result from controlling inflammation rather than a direct outcome of medication.

The correct answer is: A. Inflammatory

Explanation:

The inflammatory phase is the first phase of wound healing and begins immediately after injury, lasting approximately 3 to 5 days. This phase is essential for wound cleansing and preparation for tissue repair. During this phase, platelets aggregate to form a clot, and inflammatory cells (such as neutrophils and macrophages) migrate to the wound site to remove debris and fight potential infections. The inflammatory phase starts at the time of injury and lasts about 3-5 days. The primary goals of this phase are hemostasis (stopping bleeding) and inflammation to clear pathogens and dead cells. Key components include platelet aggregation, vasodilation, and recruitment of white blood cells (such as neutrophils and macrophages) to fight infection and promote healing.

Why the Other Options Are Incorrect:

B. Proliferative

The proliferative phase follows the inflammatory phase and typically lasts from days 4 to 21. This phase involves fibroblast activity, collagen deposition, and new blood vessel formation (angiogenesis) to create granulation tissue. It is focused on tissue repair and new cell growth, rather than the immediate response to injury.

C. Maturation

The maturation (remodeling) phase occurs after the proliferative phase, lasting weeks to months (or even up to a year in severe wounds). This phase strengthens the new tissue by remodeling collagen fibers and increasing tensile strength. It is the final phase of healing, not the initial phase.

D. Intentional

"Intentional" is not a phase of wound healing but rather a description of wounds created for medical purposes, such as surgical incisions. Wound healing phases include inflammatory, proliferative, and maturation, not "intentional."

Summary:

The inflammatory phase is the first phase of wound healing, occurring immediately after injury and lasting 3-5 days. It involves hemostasis, immune response, and inflammation to prepare the wound for repair. The proliferative phase follows with tissue regrowth, and the maturation phase focuses on strengthening the tissue. "Intentional" is not a phase of healing.