1. The nurse is collaborating with the dietitian about a patient with a Stage

III pressure ulcer. Which nutrient will the nurse most likely increase after

collaboration with the dietitian?

a. Fat

b. Protein

c. Vitamin E

d. Carbohydrate

ANS: B

Protein needs are especially increased in supporting the activity of wound

healing. The physiological processes of wound healing depend on the

availability of protein, vitamins (especially A and C), and the trace minerals of

zinc and copper. Wound healing does not require increased amounts of fats or

carbohydrates. Vitamin E will not be increased for wound healing.

2. The nurse is completing an assessment on a patient who has a Stage IV

pressure ulcer. The wound is odorous, and a drain is currently in place.

Which statement by the patient indicates issues with self-concept?

a. “I am so weak and tired. I want to feel better.”

b. “I am thinking I will be ready to go home early next week.”

“I am ready for my bath and linen change right now since this is

c. awful.”

d. “I am hoping there will be something good for dinner tonight.”

ANS: C

Body image changes can influence self-concept. The wound is odorous, and a

drain is in place. The patient who is asking for a bath and change in linens

and states that this is awful gives you a clue that he or she may be concerned

about the smell in the room. Factors that affect the patient’s perception of the

wound include the presence of scars, drains, odor from drainage, and

temporary or permanent prosthetic devices. The patient’s stating that he or

she wants to feel better, talking about going home, and caring about what is