Multidimensional Care I (Rasmussen College) (MDC1)

The correct answer is: B. Collect a culture of the purulent fluid.

Explanation:

B. "Collect a culture of the purulent fluid."

This is the correct answer because the presence of redness, swelling, and purulent drainage around the pins suggests a possible infection. The first nursing action should be to obtain a culture to identify the causative organism before initiating treatment. This ensures that the appropriate antibiotic therapy is used and prevents the spread of infection. Delaying a culture before treatment could make it harder to determine the exact bacteria causing the infection, leading to ineffective treatment.

Why the other choices are incorrect:

A. "Cleanse the skin around the pins."

This is incorrect because cleansing the area before obtaining a culture could alter the sample and potentially remove evidence of infection. While cleaning is an important part of pin care, it should be done after the culture has been collected to ensure accurate test results.

C. "Administer an antibiotic."

This is incorrect because antibiotic treatment should be based on culture results to ensure the correct medication is used. Administering an antibiotic before collecting the culture may interfere with identifying the specific pathogen, making treatment less effective.

D. "Instruct the client to complete exercises of the affected extremity."

This is incorrect because while movement and exercises can help prevent complications such as stiffness and blood clots, addressing a possible infection takes priority. Exercises should be encouraged once the infection is assessed and managed.

Summary:

When signs of infection are present around skeletal traction pins, the priority nursing action is to collect a culture of the purulent drainage before initiating treatment. This ensures accurate identification of the infection and appropriate antibiotic therapy. While cleansing the skin, administering antibiotics, and encouraging exercises are important, they should follow after obtaining a culture to prevent altering the sample or delaying effective treatment.

The correct answer is: D. Pedal pulses

Explanation:

A femur fracture is a serious injury that can lead to vascular compromise due to potential damage to blood vessels near the fracture site. The priority assessment is to check pedal pulses to ensure that blood flow to the lower extremity is adequate and that there is no circulatory impairment or compartment syndrome. Femur fractures can cause internal bleeding, swelling, or arterial damage, which may lead to ischemia (lack of blood supply) and tissue necrosis if not addressed immediately. Absent or weak pedal pulses indicate a vascular emergency requiring immediate intervention to restore blood flow.

Why the Other Choices Are Incorrect:

A. Pain

While pain assessment is important, it is not the top priority when assessing for circulatory compromise. Pain is expected with a fracture, but an absent or weak pedal pulse indicates a life-threatening issue that must be addressed first.

B. Medication History

Understanding the client’s medications (e.g., anticoagulants, steroids, or osteoporosis treatments) is important but not an immediate priority during the initial assessment of a femur fracture. Circulatory assessment takes precedence over reviewing medications.

C. Socio-economic Status

While socio-economic status is relevant for long-term care planning and rehabilitation, it is not a priority in the emergency phase of treating a femur fracture. Ensuring adequate blood supply to the leg must come first.

Summary:

The priority assessment for a client with a femur fracture is to check pedal pulses to ensure adequate circulation and prevent complications like ischemia or compartment syndrome. While pain assessment, medication history, and socio-economic status are important, they are not as urgent as confirming vascular integrity.

The correct answer is: A. Flush the exposed skin with water.

Explanation 

A. Flush the exposed skin with water.

The first action after a needlestick injury is to immediately cleanse the area to reduce the risk of infection. The nurse should flush the site with water and wash with soap for at least 30 seconds to remove any potential pathogens. If there is a mucous membrane exposure (such as the eyes, mouth, or nose), irrigate the area thoroughly with water or saline.

Explanation of Incorrect Answers:

B. Report the exposure.

While reporting the incident is crucial, it is not the first step. The priority is to flush and cleanse the area to minimize the risk of infection before reporting the incident to a supervisor or occupational health.

C. Seek medical attention.

Medical evaluation is necessary for post-exposure prophylaxis (PEP) if the source patient has a known or suspected bloodborne infection (e.g., HIV, hepatitis B, or hepatitis C). However, the first step is to flush the area and wash the skin before proceeding with medical treatment.

D. Complete an incident report.

Filling out an incident report is an important part of hospital protocol, but it is not the priority. The first action should be to flush the wound to reduce the risk of pathogen exposure, then follow up with reporting and medical evaluation.

Summary:

If a nurse is stuck by a needle, the first action is to flush the exposed skin with water and wash with soap to reduce the risk of infection. After cleansing, the nurse should report the exposure, seek medical attention, and complete an incident report.

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: 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: B. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present.

Explanation of Correct Answer:

B. Keep the nursing diagnosis in the plan of care the same since the risk factors are still present.

Even though the client’s skin integrity has not been impaired after one week, the client is still at risk due to prolonged bed rest. A risk diagnosis remains relevant as long as the risk factors persist. The nurse must continue preventive measures such as frequent repositioning, skin assessments, and pressure-relieving interventions. Removing the diagnosis prematurely could lead to neglecting essential preventive care.

Explanation of Incorrect Answers:

A. Remove the nursing diagnosis in the plan of care since it has not occurred.

This is incorrect because a risk diagnosis does not require the problem to have occurred for it to remain valid. The goal of a risk diagnosis is to prevent the problem. Since the client is still on bed rest, the risk remains, and removing the diagnosis would be inappropriate.

C. Modify the nursing diagnosis in the plan of care to impaired skin integrity.

This is incorrect because the client does not have impaired skin integrity at this time. The diagnosis should only be changed to actual impaired skin integrity if the nurse assesses signs of skin breakdown, such as redness, open wounds, or pressure injuries. Since the client’s skin is intact, the correct nursing diagnosis remains "risk for impaired skin integrity.

D. Change the nursing diagnosis in the plan of care to impaired mobility.

This is incorrect because impaired mobility and risk for impaired skin integrity are two separate diagnoses. While impaired mobility may be present due to bed rest, the original concern was about skin integrity. Changing the diagnosis would shift the focus away from preventing pressure injuries and skin breakdown, which is still a priority.

Summary:

The nurse should keep the nursing diagnosis the same because the client is still at risk for impaired skin integrity due to prolonged bed rest. Risk diagnoses remain relevant as long as risk factors exist. Removing or modifying the diagnosis without justification could lead to a lapse in preventive care, increasing the likelihood of pressure injuries.

The correct answer is D. Butterfly rash.

Explanation:

A butterfly rash (also called a malar rash) is a classic symptom of systemic lupus erythematosus (SLE). It appears as a red or purplish rash that spreads across the cheeks and the bridge of the nose, resembling the shape of a butterfly. This rash is often triggered by sun exposure and is considered a hallmark sign of lupus, appearing in about 50% of patients with SLE.

Why the Other Options Are Incorrect:

A. Heberden's nodes

These are bony swellings that develop on the distal interphalangeal joints (fingertips) in osteoarthritis (OA), not lupus. They occur due to cartilage degeneration and are not associated with autoimmune conditions like lupus.

B. Chvostek's sign

 This is a sign of hypocalcemia (low calcium levels). It is tested by tapping the facial nerve in front of the ear, causing twitching of facial muscles if calcium levels are low. It is commonly seen in hypoparathyroidism or vitamin D deficiency, not lupus.

C. Ovide’s sign

 There is no known Ovide’s sign in medical terminology. This is a distractor option.

Summary:

The butterfly rash is a hallmark symptom of lupus, appearing on the face and often triggered by sun exposure. The other options are associated with different medical conditions, not lupus.

The correct answer is: A. Inspect the client’s skin.

Explanation of Correct Answer:

A. Inspect the client’s skin

A client who has been unable to bathe for at least a month is at high risk for skin breakdown, infections, infestations (such as scabies or lice), pressure injuries, and fungal infections. The nurse's priority is to assess the client’s skin to determine the presence of wounds, rashes, or other skin conditions that may require immediate medical attention. Skin assessment is critical in prioritizing care and addressing urgent medical concerns before proceeding with hygiene assistance or social services.

Explanation of Incorrect Answers:

B. Provide a towel and show the client to the shower

While hygiene is important, the nurse must first assess the client for any skin integrity issues, infections, or other medical concerns that could worsen with bathing (e.g., open wounds or infected ulcers). Bathing should be done after the nurse determines that it is safe and appropriate.

C. Ask if the client has been to a homeless shelter recently

Gathering social history is important for long-term care planning, but it is not the immediate priority. The priority is to assess the client’s physical condition (including skin health) before addressing social needs.

D. Call a social worker

A social worker can help the client with housing, resources, and support services, but the nurse’s first priority is a physical assessment to identify any urgent medical needs. The nurse can involve a social worker after ensuring the client is medically stable.

Summary:

The priority for a homeless client who has not bathed for a month is to inspect the skin for infections, wounds, or other medical concerns. While hygiene assistance, social history, and social services are important, assessing the client's physical condition takes precedence to ensure there are no urgent medical issues.

The correct answer is:  A. Shearing or friction

Explanation:

Shearing and friction are the forces responsible for the injury to the heel while the client was being moved up in bed. These forces occur when skin moves in one direction while underlying tissues and bone move in another, leading to skin breakdown and tissue damage. Friction happens when the skin rubs against a surface, like bed linens, causing superficial damage (e.g., abrasions or skin tears). Shearing occurs when deeper tissues are pulled in one direction while the skin stays in place, leading to damage in the underlying layers of tissue, which can result in pressure injuries. When a client is pulled up in bed without proper lifting techniques, heels, sacrum, and elbows are at high risk of shearing injuries due to the force applied against the sheets.

Why the Other Choices Are Incorrect:

B. Pressure or gravity

Pressure injuries occur when prolonged force is applied to an area (e.g., lying in one position for too long), but this scenario involves an immediate injury during repositioning, not prolonged pressure. Gravity can contribute to sliding down in bed, but the injury here is caused by rubbing and pulling, not direct pressure.

C. Chemical or pressure

There is no mention of chemical exposure in this scenario. Pressure injuries develop over time, whereas the client sustained an immediate injury during movement.

D. Twisting and bending

Twisting and bending forces typically result in muscle strains, joint injuries, or ligament damage, rather than skin breakdown or shearing injuries. The injury in this case is to the heel, which suggests friction and shearing, not twisting or bending.

Summary:

The injury to the client’s heel was caused by shearing or friction, which occurs when the skin drags or slides against a surface while the underlying tissues move in a different direction. This type of injury is common when repositioning clients improperly, especially if heels are not lifted or protected. Proper lifting techniques, using draw sheets, and heel protectors can help prevent shearing injuries.