Author Question: The nurse assessing a client with a surgical wound determines that care has been effective when ... (Read 74 times)

silviawilliams41 · **on:** Jul 22, 2018

The nurse assessing a client with a surgical wound determines that care has been effective when which of the following is assessed?

1. There is only a scant amount of purulent drainage on the dressing.
2. The client performs wound care independently.
3. A small area of erythema and edema is present.
4. The client's temperature is 100F.

Question 2

An elderly client tells the nurse that when back pain begins to occur, the client rests in bed until it feels better. Which of the following nursing diagnoses would be appropriate for this client?

1. Acute Pain
2. Risk for Injury
3. Ineffective Coping
4. Deficient Knowledge

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

Answer to Question 1

2. The client performs wound care independently.

Rationale:
Evidence of effective care for a client with a surgical wound includes the client performing wound care independently. Purulent drainage and an elevated temperature could mean the wound is infected. Erythema and edema could indicate the wound is inflamed or infected.

Answer to Question 2

4. Deficient Knowledge

Rationale:
Since there is little scientific evidence to support the benefit of bed rest with back pain, the client is demonstrating a lack of awareness of the need to stay active. The client may also benefit from instructions regarding back exercises. The back pain has not been identified as being acute, so this nursing diagnosis may or may not be appropriate. There is no information to suggest that the client is at risk for injury. There is no information to suggest that the client is not coping effectively with the back pain.