Nursing practice questions with comprehensive rationales
NurseDive Free Nursing Practice Question
A patient who has sustained a burn injury will undergo wound debridement. The nurse includes which explanation when explaining the purpose of burn wound debridement?
A. Prevention of infection and promote healing.
Prevention of infection and promote healing. Debridement helps remove dead tissue, which prevents infection and promotes healing.
B. Promoting movement in the affected area.
Promoting movement in the affected area: While movement is important, debridement is primarily for removing necrotic tissue to prevent infection.
C. To increase the effectiveness of the skin graft.
To increase the effectiveness of the skin graft: Debridement does help prepare the wound bed for grafting, but its main purpose is infection control and healing.
D. Promoting suppuration of the wound.
Promoting suppuration of the wound: Suppuration is not a goal of debridement; it is about cleaning the wound and preventing infection.
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Full Explanation
A. Prevention of infection and promote healing. Debridement helps remove dead tissue, which prevents infection and promotes healing.
B. Promoting movement in the affected area: While movement is important, debridement is primarily for removing necrotic tissue to prevent infection.
C. To increase the effectiveness of the skin graft: Debridement does help prepare the wound bed for grafting, but its main purpose is infection control and healing.
D. Promoting suppuration of the wound: Suppuration is not a goal of debridement; it is about cleaning the wound and preventing infection.
Similar Questions
A patient admitted to the hospital after a motorcycle crash that has left him paralyzed from the waist down tells the nurse he has feelings of helplessness and hopelessness. What other feelings may the patient have that should be recognized?
A. Anger
Anger: Anger is a common response but not necessarily the most immediate concern in the context of severe emotional distress and potential suicidal thoughts.
B. Fear
Fear: Fear is a possible reaction, but suicidal ideation is a more serious concern in the context of helplessness and hopelessness.
C. Isolation
Isolation: Isolation may occur, but suicidal ideation is a critical issue that requires immediate attention.
D. Suicidal ideation
Suicidal ideation: Feelings of helplessness and hopelessness can be strong indicators of suicidal ideation, which should be assessed and addressed urgently.
Full Explanation
A. Very disruptive to a person in society: This description is judgmental and not specific to documenting behavior objectively.
B. Differing from socially acceptable behavior: Documenting behavior as differing from socially acceptable norms provides an objective, non-judgmental account of the patient’s behavior.
C. Causing the person to be involved in problems: This focuses on the outcomes of the behavior rather than describing the behavior itself.
D. Resulting from an inability to exercise control: This may imply a lack of control but does not objectively describe the behavior for documentation purposes.
How should the nurse document the behavior of a patient with mental illness?
A. Very disruptive to a person in society
Very disruptive to a person in society: This description is judgmental and not specific to documenting behavior objectively.
B. Differing from socially acceptable behavior
Differing from socially acceptable behavior: Documenting behavior as differing from socially acceptable norms provides an objective, non-judgmental account of the patient’s behavior.
C. Causing the person to be involved in problems
Causing the person to be involved in problems: This focuses on the outcomes of the behavior rather than describing the behavior itself.
D. Resulting from an inability to exercise control
Resulting from an inability to exercise control: This may imply a lack of control but does not objectively describe the behavior for documentation purposes.
Full Explanation
A. Very disruptive to a person in society: This description is judgmental and not specific to documenting behavior objectively.
B. Differing from socially acceptable behavior: Documenting behavior as differing from socially acceptable norms provides an objective, non-judgmental account of the patient’s behavior.
C. Causing the person to be involved in problems: This focuses on the outcomes of the behavior rather than describing the behavior itself.
D. Resulting from an inability to exercise control: This may imply a lack of control but does not objectively describe the behavior for documentation purposes.
After finding the patient with diabetes eating candy, the nurse reminds the patient that the candy will elevate blood sugar levels. The patient's response is: "It's only a little bit, and it won't do anything." Which defense mechanism is the patient using?
A. Conversion
Conversion: Conversion involves a psychological conflict being expressed as physical symptoms, which does not fit the patient's response.
B. Repression
Repression: Repression involves unconsciously blocking out unpleasant thoughts or memories, which is not evident in the patient’s response.
C. Denial
Denial: Denial involves refusing to accept reality or facts, which fits the patient’s statement that the candy won’t affect their blood sugar levels.
D. Regression
Regression: Regression involves reverting to earlier developmental stages or behaviors, which does not apply to this situation.
Full Explanation
A. Conversion: Conversion involves a psychological conflict being expressed as physical symptoms, which does not fit the patient's response.
B. Repression: Repression involves unconsciously blocking out unpleasant thoughts or memories, which is not evident in the patient’s response.
C. Denial: Denial involves refusing to accept reality or facts, which fits the patient’s statement that the candy won’t affect their blood sugar levels.
D. Regression: Regression involves reverting to earlier developmental stages or behaviors, which does not apply to this situation.