The nurse assesses a client's wound. What type of wound requires immediate intervention by the nurse?

Correct Answer: A

Rationale: In this scenario, the correct answer is A) Laceration, which requires immediate intervention by the nurse. A laceration is a deep cut or tear in the skin that may result in significant bleeding and tissue damage. Immediate nursing intervention is crucial to control bleeding, prevent infection, promote wound healing, and provide proper wound care. Option B) Abrasion is a superficial injury that involves the top layers of the skin and typically does not cause severe bleeding or tissue damage. While it still requires nursing assessment and care, it does not usually necessitate immediate intervention compared to a laceration. Option C) Contusion refers to a bruise, which involves damage to the blood vessels beneath the skin, causing discoloration but not an open wound. Contusions usually do not require immediate intervention unless there are signs of more serious internal injuries. Option D) Ulceration is the formation of an open sore or wound that is usually chronic in nature. While ulcers require ongoing nursing care and management to promote healing and prevent complications, they do not typically require immediate intervention in the same way that a laceration does. In an educational context, understanding the urgency of different wound types is vital for nurses to prioritize care effectively. Knowing which wounds require immediate attention helps nurses provide timely and appropriate interventions to prevent complications and promote optimal patient outcomes.

Correct Answer: B

Rationale: For a client with severe neutropenia, it is crucial to recommend a snack that is low in bacteria to reduce the risk of infection. Yogurt with fresh berries is an excellent choice as it is not only low in bacteria but also provides nutritional value. Baked apples with raisins (choice A) may not be ideal as the preparation process could introduce bacteria. Avocados and cheese (choice C) may not be the best option due to their potential bacterial content. Fresh fruit salad (choice D) may have a higher risk of bacterial contamination compared to yogurt with fresh berries.

Correct Answer: B

Rationale: The correct answer is B. Altered consciousness within the first 24 hours after a temporal injury is a classic sign of epidural hematoma, which is a neurosurgical emergency. This finding occurs due to the rapid expansion of the hematoma, causing compression of the brain. Nausea and vomiting (choice A) are more commonly associated with other types of head injuries, such as concussion. Severe headache and blurred vision (choice C) are symptoms seen in various head injuries but are not specific to epidural hematomas. Loss of motor function on the affected side (choice D) is more indicative of a different type of head injury, such as a contusion or intracerebral hematoma.

Correct Answer: B

Rationale: The most important instruction for the nurse to provide to a client following a cystectomy and urinary diversion is to report any signs of cloudy urine output. Cloudy urine may indicate infection, which is a serious concern in clients with a urinary diversion. Instructing the client to report any signs of infection immediately is crucial to prevent complications. Avoiding heavy lifting is important for postoperative recovery but not as critical as identifying a potential infection. Drinking an adequate amount of water is generally beneficial for health but not the most crucial instruction in this scenario. While monitoring for signs of infection at the surgical site is essential, cloudy urine is a more specific and immediate indicator of a potential problem in clients with urinary diversions.

Correct Answer: B

Rationale: The correct answer is B: Assess for signs of hypocalcemia. After a thyroidectomy, monitoring for hypocalcemia is crucial because damage to the parathyroid glands during surgery can result in low calcium levels, which may cause life-threatening complications. Monitoring respiratory rate and rhythm (choice A) is important but not the most critical in this situation. Monitoring for elevated body temperature (choice C) is less of a priority post-thyroidectomy. Checking blood pressure every 30 minutes (choice D) is not as vital as monitoring for hypocalcemia in this context.