Multidimensional Care I (Rasmussen College) (MDC1)

The correct answers are:

A. Wash your hands thoroughly.

C. Avoid raw fruits and vegetables.

D. Avoid crowds.

Explanation:

Clients with acquired immunodeficiency syndrome (AIDS) have a weakened immune system due to severe immunosuppression caused by human immunodeficiency virus (HIV). This makes them highly vulnerable to opportunistic infections. To reduce infection risk, the nurse should educate the client on infection prevention strategies.

A. Wash your hands thoroughly 

Frequent and thorough handwashing with soap and water is one of the best ways to prevent infections. Clients should wash hands before eating, after using the bathroom, and after touching potentially contaminated surfaces.

C. Avoid raw fruits and vegetables 

Raw produce may contain bacteria or parasites that could lead to infections. Cooking fruits and vegetables helps eliminate harmful pathogens. If raw foods are consumed, they must be thoroughly washed and peeled

D. Avoid crowds 

Large crowds increase the risk of exposure to infections like the flu, colds, and other contagious illnesses. Clients should avoid close contact with sick individuals and wear a mask in crowded places when necessary.

Why the Other Options Are Incorrect:

B. Avoid cleaning your toothbrush with bleach

Clients with AIDS are at higher risk for oral infections, so it is recommended to disinfect toothbrushes regularly. Soaking the toothbrush in bleach or hydrogen peroxide can help reduce bacterial growth.

E. Share toothpaste with family members 

Sharing toothpaste can lead to cross-contamination of bacteria and viruses. Each person should have their own toothpaste to minimize infection risk.

Summary:

To reduce infection risk in clients with AIDS, the nurse should educate them on frequent handwashing, avoiding raw produce, and staying away from crowded places. Toothbrushes should be cleaned with disinfectant, and personal hygiene items, such as toothpaste, should never be shared.

The correct answer is: C. Raise the head of the bed.

Explanation:

When a client’s oxygen saturation drops to 85%, they are experiencing hypoxemia, which requires immediate intervention to improve oxygenation. The first action should be raising the head of the bed to facilitate lung expansion and improve ventilation. This is a simple and effective intervention that can enhance oxygenation before considering more invasive measures.

Why the Other Options Are Incorrect:

A. Call the provider – Incorrect. While notifying the provider is important, it is not the first action. The nurse must intervene immediately to improve the client’s oxygenation before calling the provider. Oxygen saturation at 85% is an urgent concern, and delaying intervention could worsen the patient’s condition.

B. Place the client in the lithotomy position – Incorrect. The lithotomy position (lying on the back with legs elevated in stirrups) is used for gynecological or rectal exams and does not aid in oxygenation. This position could worsen respiratory function by restricting lung expansion.

D. Obtain pain medication – Incorrect. While pain management is important, pain medication does not directly address hypoxemia. Administering opioids, for example, could further depress respiration and worsen the client’s oxygenation.

Summary:

The priority intervention when a client has an oxygen saturation of 85% is to raise the head of the bed to improve ventilation and oxygenation. After this, additional interventions such as administering oxygen, assessing for underlying causes, and notifying the provider can be performed as needed.

The correct answer is: B. Purulent

Explanation:

Purulent drainage is thick, yellow, green, or brown fluid that indicates infection. It is made up of dead white blood cells, bacteria, and tissue debris. The creamy, thick yellow drainage described in the question suggests an infected wound, making purulent the correct choice.

Why This Answer Is Correct:

B. Purulent

Thick, creamy, yellow drainage is characteristic of purulent exudate. Often associated with infection and inflammation. May have a foul odor and can be green, brown, or yellow, depending on the type of bacteria present.

Why the Other Options Are Incorrect:

A. Serous 

Serous drainage is clear or pale yellow and thin, watery in consistency. It is common in normal wound healing and not a sign of infection.

C. Serosanguineous 

Serosanguineous drainage is a mixture of clear (serous) fluid and blood (sanguineous), giving it a pink or light red appearance. It is thin and watery, not thick or creamy, and is common in early wound healing.

D. Sanguineous

Sanguineous drainage is fresh, bright red blood. It is usually seen in deep wounds or those with active bleeding, not in infected wounds.

Summary:

The creamy, thick yellow drainage described in the question is purulent exudate, which indicates infection. Serous, serosanguineous, and sanguineous exudates have different colors and consistencies and are not associated with infection. The nurse should assess the wound further, monitor for signs of systemic infection (fever, redness, swelling, increased pain), and notify the healthcare provider if necessary.

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: C. Pieces of bone and cartilage floating.

Explanation:

In osteoarthritis (OA), the cartilage that cushions the joints gradually breaks down due to wear and tear. As the cartilage deteriorates, bone surfaces start rubbing against each other, and fragments of bone and cartilage may break off and float in the joint space. This leads to crepitus, an audible grating or cracking sound heard when the joint moves. It is a common finding in OA and results from joint degeneration rather than an inflammatory process.

Why the Other Options Are Incorrect:

A. Popping bursae from standing

 The bursa is a fluid-filled sac that reduces friction between bones and soft tissues. Bursitis, an inflammation of the bursa, can cause pain and swelling but does not produce crepitus in OA.

B. A herniated area disk diseases joint

 Herniated discs occur in the spine, not in the knee joints. They result from the protrusion of the intervertebral disc pressing on spinal nerves, causing back pain, numbness, or weakness, not crepitus in the knee.

D. Years of an autoimmune process

 While rheumatoid arthritis (RA) is an autoimmune disease that affects joints, crepitus in OA is caused by mechanical wear and tear, not autoimmune inflammation. RA primarily leads to synovial inflammation, joint deformity, and stiffness, rather than bone and cartilage fragments causing crepitus.

Summary:

Crepitus in osteoarthritis occurs due to pieces of bone and cartilage floating in the joint, which cause a grating sound when the knee moves. The other options describe unrelated conditions, such as bursitis, herniated discs, and autoimmune diseases like rheumatoid arthritis.

The correct answer is: D. Use a mechanical lift to reposition the client every 2 hours.

Explanation:

Friction and shear injuries occur when the skin is dragged across a surface, causing damage to the underlying tissue. This is a major concern in geriatric, immobile, and sedated clients, especially those who are intubated, as they cannot reposition themselves. Using a mechanical lift helps reduce friction and shear by lifting rather than dragging the client. It ensures safe repositioning without excessive pressure on the skin, reducing the risk of pressure injuries (bedsores). Repositioning every 2 hours is a standard nursing intervention to prevent skin breakdown.

Why the other choices are incorrect:

A. Postpone daily bed bath

This is incorrect because daily hygiene is important for infection prevention, skin integrity, and overall comfort. While excessive bathing can dry out the skin, proper skin care with moisturizers helps prevent skin breakdown. The key to reducing shear and friction is safe repositioning, not avoiding hygiene care.

B. Elevate the client’s head of the bed to 45 degrees

This is incorrect because elevating the head of the bed above 30 degrees increases shear forces. When the bed is elevated too high, the client’s body slides downward, causing the skin and deeper tissues to move at different rates, increasing the risk of skin damage. The head of the bed should be kept at 30 degrees or lower unless contraindicated (e.g., risk for aspiration).

C. Caregiver independently slides the client up in bed

This is incorrect because sliding a client up in bed without using proper techniques (e.g., lift sheet, draw sheet, or mechanical lift) creates significant shear forces. This can tear fragile skin, leading to pressure injuries. Instead, a two-person assist with a lift sheet or mechanical lift should be used.

Summary:

To minimize friction and shear injury, a mechanical lift should be used to reposition the client every 2 hours. This prevents dragging of the skin and reduces pressure injury risk. Proper positioning techniques, including keeping the head of the bed at 30 degrees or lower when possible, using lift sheets, and ensuring regular skin care, are essential in preventing skin breakdown in geriatric and immobile clients.

The correct answer is: A. The nurse washes their hands before entering the room.

Explanation:

In a client with lupus who is receiving steroids, one of the most important priorities is preventing infection. Steroids suppress the immune system, making the client more susceptible to infections. Proper hand hygiene is one of the simplest and most effective ways to prevent the transmission of infections. The nurse washing their hands before entering the room ensures that the client is not exposed to harmful pathogens, which is a critical intervention in this situation.

Why the other choices are incorrect:

B. Assist with the enhancement of social well-being by providing activities.

This is incorrect because while promoting social well-being and providing activities is important for overall health, it is not the priority when the client is receiving steroids for a flare-up. The focus should be on preventing infection and managing the immunosuppressive effects of steroids, which are more immediate concerns.

C. Assess the client's support system.

This is incorrect because although assessing the support system is an important aspect of overall care, it is not the immediate priority when the client is receiving steroids. Preventing infection and addressing immediate medical needs, such as the side effects of steroids, take precedence over evaluating social support in this case.

D. Ensure privacy by keeping the door always closed.

This is incorrect because ensuring privacy by keeping the door closed is not as critical as preventing infection. While privacy is important for the client's dignity, it does not address the immediate risk of infection related to the immunosuppressive effects of steroids. Hand hygiene should be the priority.

Summary:

The priority nursing intervention for a client with lupus who is receiving steroids is to wash hands before entering the room. This helps prevent infections, which are a significant risk due to the immunosuppressive effects of steroids. While other interventions, such as promoting social well-being or assessing support, are important, preventing infection takes precedence.

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 answers are:

B. Drink at least 2 to 3 L of fluids per day

C. Eat high-calorie foods

E. Choose foods high in protein

Explanation:

For a client with acquired immunodeficiency syndrome (AIDS), the body requires proper nutrition to maintain immune function, prevent weight loss, and manage the effects of the disease and treatment. Key aspects of nutrition and hydration include:

B. Drink at least 2 to 3 L of fluids per day:

Adequate hydration is crucial for clients with AIDS because they are at risk for dehydration due to factors such as fever, diarrhea, or side effects of medications. Drinking 2 to 3 liters of fluids daily helps maintain fluid balance and supports overall health.

C. Eat high-calorie foods:

AIDS often leads to weight loss and muscle wasting, so consuming high-calorie foods is essential to meet the increased energy needs and prevent further weight loss. This may include nutrient-dense foods like whole grains, nuts, and avocados to provide sufficient calories for maintaining body mass.

E. Choose foods high in protein:

Protein is critical for maintaining and repairing body tissues, including the immune system, which is compromised in clients with AIDS. Choosing high-protein foods, such as lean meats, eggs, beans, and dairy, supports immune function and helps prevent muscle wasting.

Why the other choices are incorrect:

A. Include many fresh fruits and vegetables in your diet:

While fruits and vegetables are important for providing vitamins, minerals, and fiber, they may carry a risk of foodborne illness in clients with AIDS due to their compromised immune system. Raw fruits and vegetables should be avoided or carefully washed and peeled to reduce the risk of infections, and cooked vegetables are safer options.

D. Lower your caloric intake:

This is incorrect because clients with AIDS often have an increased metabolic rate due to the disease, and they also may experience anorexia, nausea, and weight loss. Lowering caloric intake is not recommended and can exacerbate malnutrition. In fact, a higher caloric intake is essential to support the body's energy demands.

Summary:

The nurse should teach the client with AIDS to drink adequate fluids, eat high-calorie foods, and consume foods rich in protein to support immune function, prevent malnutrition, and manage the symptoms of the disease. Fresh fruits and vegetables should be handled with care, and a lower caloric intake is not recommended in this case.