A nurse is caring for a client with bacterial pneumonia and a temperature of 104°F (40.0°C). Yesterday, the client's temperature was 102°F (38.9°C). The health care provider on call prescribes cool compresses for the client to help lower the fever. The client insists that the nurse bring warm blankets because they will help the client to recover more quickly. The nurse recognizes that the client's request is an example of:

Correct Answer: A

Rationale: Client beliefs reflect culture. Requesting warm blankets is a ritual, per nursing texts, possibly tied to traditional healing (e.g., sweating out illness). Stereotyping is nurse assumption, not client action. Competence is nurse skill. No Choice D exists. This cultural ritual guides respectful care, making it correct.

Correct Answer: B

Rationale: A burn involving the epidermis and part of the dermis is classified as a partial-thickness burn, making choice B the correct answer. This type of burn typically presents with blisters, significant pain due to exposed nerve endings, and redness as blood vessels in the dermis are affected. It may heal spontaneously within two to three weeks with proper care or require skin grafting if deeper layers are involved. Superficial burns only affect the epidermis, causing mild pain and erythema without blisters, and heal quickly within days without scarring. Full-thickness burns extend through the epidermis, dermis, and into underlying tissues like fat or muscle, resulting in a charred appearance, no pain due to nerve destruction, and the need for surgical intervention. Deep partial-thickness burns involve most of the dermis, presenting with white or red skin and severe pain, often requiring grafting due to slower healing. The distinction lies in the depth of tissue involvement, and partial-thickness best matches the description provided.

Correct Answer: D

Rationale: as the nurse should monitor for both hypersensitivity or allergic reaction and leukopenia or decreased white blood cell count when using silver sulfadiazine (Silvadene) on a burn wound. This topical antimicrobial can cause allergic reactions like rash, itching, or swelling, which may escalate to severe symptoms like difficulty breathing, requiring immediate attention. It can also lead to leukopenia, a drop in white blood cells, increasing infection risk, necessitating regular blood count monitoring. Hyperglycemia isn't a typical adverse reaction to Silvadene; it may occur in burn patients due to stress or infection, not the cream itself. Since both A and B are valid concerns supported by the need for baseline and periodic complete blood counts choice D encompasses the full scope of critical monitoring, ensuring comprehensive care for potential complications.

Correct Answer: D

Rationale: as hydrocolloid dressings stimulate autolytic debridement of necrotic tissue, a key advantage for a diabetic foot ulcer. These dressings are occlusive, forming a gel-like layer over the wound that traps moisture and enzymes, naturally breaking down dead tissue without mechanical intervention. This process is gentle, reducing trauma to surrounding healthy tissue, which is crucial for diabetic patients prone to slow healing. While providing a moist environment is true, it's not unique to hydrocolloids other dressings like hydrogels also do this making it less specific. Absorbing large amounts of exudate is incorrect, as hydrocolloids handle only minimal to moderate drainage, unlike alginates, and can leak if overwhelmed. Allowing frequent inspection is false; hydrocolloids are opaque and typically left in place for days, not designed for regular viewing. Autolytic debridement stands out as the distinct benefit, supporting healing in chronic wounds like diabetic ulcers by clearing necrotic debris efficiently.

Correct Answer: C

Rationale: Discontinuing NPWT and applying a moist dressing is the correct action when wound edges are approximated and granulation tissue fills the bed. This indicates successful healing progression, as NPWT has achieved its goals removing fluid, reducing edema, and stimulating tissue growth. Continuing beyond this point risks overgranulation or maceration, while a moist dressing supports epithelialization in the final stages. Increasing dressing changes disrupts healing and isn't warranted with good progress. Decreasing pressure reduces efficacy unnecessarily, as the therapy's work is largely done. Continuing until complete closure may over-treat, causing complications like tissue overgrowth. Transitioning to a moist dressing aligns with wound healing phases, shifting from granulation support to surface closure, reflecting evidence-based practice for chronic wound management.