A client from a nursing home arrives at an acute care facility for treatment related to complications of chronic obstructive pulmonary disease. A nurse performing the admission assessment notes the presence of a large stage III pressure ulcer. The client's child asks if the hospital can 'treat the sore.' What is the nurse's best initial response?

Correct Answer: D

Rationale: The correct answer is D because it addresses the immediate need for wound care assessment and management by involving the physician and wound care nurse. This response shows a proactive approach to the client's care. Choice A does not directly address the need for wound care and focuses more on stopping it from getting worse without a clear plan. Choice B is not helpful as it only mentions filing a report without addressing the treatment plan. Choice C jumps to a specific intervention without involving the healthcare team in decision-making. Overall, choice D is the best initial response as it prioritizes collaboration and appropriate care planning for the client's pressure ulcer.

Correct Answer: C

Rationale: The correct answer is C because it acknowledges Aaron's feelings of discouragement and shows empathy by recognizing the challenges he is facing. By stating that he is trying to cope with a lot of concerns right now, the nurse validates his emotions and offers support. Options A, B, and D are incorrect because they do not address Aaron's feelings or provide emotional support. Option A is dismissive and focuses on correcting Aaron's wording, Option B is directive and does not validate his emotions, and Option D provides false reassurance without addressing his emotional state.

Correct Answer: A

Rationale: The correct answer is A: Serum electrolyte levels. In a client exhibiting signs of systemic infection, diagnostic tests typically include white blood cell differential and count to assess for infection. Urinalysis may reveal signs of infection in the urinary system. Serum electrolyte levels are not directly related to diagnosing systemic infection and would not be a priority in this scenario. Monitoring electrolyte levels is important for other conditions like dehydration or kidney disease.

Correct Answer: A

Rationale: The correct answer is A: Surgery. In the case of gangrene of the toe, surgical intervention is often necessary to remove the dead tissue and prevent further spread of infection. Surgery can involve amputation of the affected toe or foot to save the client's life and prevent complications. Debridement (choice B) is a related procedure but may not be sufficient in severe cases of gangrene. Myringotomy (choice C) is a procedure to relieve pressure or drain fluid from the middle ear, not related to gangrene treatment. Wound irrigation (choice D) is a general wound care procedure and may not address the severity of gangrene effectively.

Correct Answer: B

Rationale: The correct answer is B: Edema of the affected eye. Orbital cellulitis is characterized by inflammation and infection of the tissues surrounding the eye, leading to swelling and edema. This assessment finding is expected due to the inflammatory response. Sunken eyes (A) are not typically associated with orbital cellulitis. Increased acuity of the affected eye (C) is unlikely as the infection can impair vision. Elevated blood pressure (D) is not a typical assessment finding for orbital cellulitis.