A nurse assesses clients on a medical-surgical unit. Which client should the nurse evaluate for a wound infection?

Correct Answer: C

Rationale: The correct answer is C because a white blood cell count of 23,000/mm³ indicates a potential infection. Elevated WBC count is a common sign of infection as the body responds to pathogens. The other choices are incorrect because: A: Blood cultures pending do not necessarily indicate a wound infection. B: Thin, serous wound drainage is normal in some cases and does not always indicate infection. D: Decrease in wound size is a positive sign of healing, not infection. In summary, the client with an elevated WBC count should be evaluated for a wound infection due to the potential indication of an inflammatory response.

Correct Answer: C

Rationale: The correct answer is C: Full thickness. This categorization is based on the description of white and leather-like appearance, indicating complete destruction of the epidermis and dermis layers. This type of injury is characteristic of full-thickness burns, also known as third-degree burns. Partial-thickness deep burns (A) involve damage to the dermis but not the full thickness, while partial-thickness superficial burns (B) only affect the epidermis and part of the dermis. Superficial burns (D) are limited to the epidermis only. The specific description of the burns in this case clearly aligns with full-thickness burns, making choice C the most appropriate categorization.

Correct Answer: D

Rationale: The correct answer is D because staying out of the sun between 10 AM and 2 PM reduces exposure to the strongest UV rays, decreasing the risk of skin damage. A is incorrect as SPF should be at least 30. B is wrong as water-resistant sunscreens require reapplication after swimming. C is incorrect as increasing sun exposure can lead to more skin damage. In summary, option D is the most effective in reducing sun damage risk compared to the other choices.

Correct Answer: D

Rationale: The correct answer is D: Ask the patient to describe the impact of psoriasis on quality of life. This is the first action the nurse should take to understand the patient's perspective, feelings, and how psoriasis is affecting their daily life. By doing so, the nurse can assess the severity of the social withdrawal and emotional impact, which can guide further interventions. Choice A is incorrect because enrolling in a worker-retraining program does not address the immediate social withdrawal and emotional impact due to psoriasis. Choice B is incorrect as encouraging the patient to volunteer for community projects may not be suitable or effective in addressing the patient's current emotional distress. Choice C is incorrect because suggesting cosmetics to cover the lesions only focuses on the physical appearance and does not address the underlying emotional and social issues.

Correct Answer: B

Rationale: The correct answer is B because turning immobile clients every two hours is crucial for preventing pressure ulcers. The UAP asking for a meal break before turning the clients neglects their safety and well-being. Choice A is incorrect because elevating the head of the bed for a client who can feed themselves is appropriate. Choice C is incorrect as restocking unsterile gloves is not an urgent issue. Choice D is incorrect because mixing Thick-It into water for a client with swallowing difficulties is within the UAP's scope of practice.