A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?

Dry brown eschar

Wound tissue firm to palpation

Light yellow exudate

Dark red granulation tissue

Answer and Explanation

The Correct Answer is D

A. Dry brown eschar is a sign of necrotic tissue, which indicates that the wound is not healing properly. Eschar needs to be removed for proper healing to occur.

B. Wound tissue firm to palpation is not a typical sign of healing. Healing tissue tends to be softer, while firm tissue could indicate fibrosis or an abnormal healing process.

C. Light yellow exudate can indicate the presence of infection or the early stages of healing, but it is not as specific a sign of healing as granulation tissue. Granulation tissue is a more definitive sign of healing.

D. Dark red granulation tissue is a sign of healthy healing tissue. It consists of new blood vessels and is an indication that the wound is in the proliferative phase of healing, which is a positive sign.

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Correct Answer is D

Explanation

A. The PPD test is typically evaluated 48 to 72 hours after administration, so returning in another 48 hours is not necessary at this point.

B. The frequency of PPD testing depends on the individual's risk factors and exposure to tuberculosis (TB), not necessarily on an annual basis.

C. The test does not need to be repeated at this time. A 12 mm induration is a positive result for individuals with certain risk factors, and further evaluation is needed rather than repeating the test.

D. A 12 mm induration is considered a positive result for the PPD test in individuals with moderate risk factors for TB. The nurse should instruct the client to follow up with their provider for further evaluation, which may include a chest X-ray or other diagnostic tests.

A. Loss of peripheral vision B. Disequilibrium with movement C. Inability to smell D. Deviation of the tongue from midline

Correct Answer is B

Explanation

A. Loss of peripheral vision is associated with impairment of the optic nerve (cranial nerve II), not the vestibulocochlear nerve. The vestibulocochlear nerve is responsible for hearing and balance, not vision.

B. Disequilibrium with movement is a classic sign of impaired function of the vestibulocochlear nerve (cranial nerve VIII). This nerve has two branches: the cochlear branch (responsible for hearing) and the vestibular branch (responsible for balance). Damage to the vestibular branch can cause dizziness, vertigo, and difficulty maintaining balance.

C. Inability to smell is associated with impairment of the olfactory nerve (cranial nerve I), not the vestibulocochlear nerve.

D. Deviation of the tongue from midline is typically seen with impairment of the hypoglossal nerve (cranial nerve XII), not the vestibulocochlear nerve.

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A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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