Author Question: In developing a nursing care plan for increasing activity tolerance in a patient, the nurse should ... (Read 32 times)

torybrooks · **on:** Jul 22, 2018

In developing a nursing care plan for increasing activity tolerance in a patient, the nurse should (Select all that apply.)

a. Use generalized therapies because they work for everyone.
b. Consult with members of the health care team.
c. Avoid goals published by the American College of Sports Medicine.
d. Involve the patient and the patient's family in designing an exercise plan.
e. Consider the patient's ability to increase activity level.

Question 2

The nurse is caring for a patient with a stage IV pressure ulcer. The nurse recalls that a pressure ulcer takes time to heal and is an example of

a. Primary intention.
b. Partial-thickness wound repair.
c. Full-thickness wound repair.
d. Tertiary intention.

helenmarkerine · **Reply #1 on:** Jul 22, 2018

Answer to Question 1

B, D, E
When planning care, the nurse should consult/collaborate with members of the health care team to increase activity, involve the patient and family in designing an activity and exercise plan (especially if family members are also providers of care), and consider the patient's ability to increase activity level. Therapies should be individualized to the patient's activity tolerance. Information from the American College of Sports Medicine serves as a standard that the nurse should use when applying activity and exercise goals.

Answer to Question 2

C
Pressure ulcers are full-thickness wounds that extend into the dermis and heal by scar formation because the deeper structures do not regenerate, hence the need for full-thickness repair. The full-thickness repair has three phases: inflammatory, proliferative, and remodeling. A wound heals by primary intention when wounds such as surgical wounds have little tissue loss; the skin edges are approximated or closed, and the risk for infection is low. Partial-thickness repairs are done on partial-thickness wounds that are shallow, involving loss of the epidermis and maybe partial loss of the dermis. These wounds heal by regeneration because the epidermis regenerates. Tertiary intention is seen when a wound is left open for several days, and then the wound edges approximated. Wound closure is delayed until risk of infection is resolved.