Skin Integrity and Wound Care: Analyze Cue and Prioritize Hypotheses; Plan and Generate Solutions 100% Pass

Skin Integrity and Wound Care: Analyze Cue and Prioritize Hypotheses; Plan and Generate Solutions 100% Pass Which categories can the nurse use to organize and link the patient's skin integrity cues? 1. type of wound 2. type of wound bed tissue 3. type of infection 4. unexpected assessment findings 5. unexpected lab findings of wound 2. type of wound bed tissue 3. unexpected findings from assessment 4. findings from laboratory or diagnostic tests, or a combination of these. Which components are likely damaged when the nurse chooses the hypothesis Impaired Skin Integrity for a patient? 1. Dermis 2. Bone 3. Muscle 4. Tendon 5. Epidermis 6. Subcutaneous tissue 1. dermis 2. epidermis Which hypothesis would the nurse select for a patient with a breakdown in the dermis from external forces? 1. Impaired Skin Integrity 2. Risk for Impaired Skin Integrity 3. Impaired Tissue Integrity 4. Burn Wound 1. Impaired skin integrity Which patient would the nurse see first after receiving report? 1. A patient with a profusely bleeding wound 2. A patient with a wound dehiscence 3. A patient with an early wound infection 4. A patient experiencing a wound from a surgical incision 1. A patient with profusely bleeding wound Which overall goal would the nurse develop for a patient with a leg incision? 1. Encourage participation in position changes within 48 hours. 2. Reduce pain level to a 5/10 after treatment. 3. Promote complete healing of wound. 4. Enhance generation of solutions. 3. promote complete healing of the wound The nurse would use which organization's guidelines