A nurse is assessing a client who has a pressure ulcer. Which of the following findings should the nurse expect as an indication the wound is healing?
Wound tissue firm to palpation
Dry brown eschar
Light yellow exudate
Dark red granulation tissue
The Correct Answer is D
A pressure ulcer is a localized injury to the skin and underlying tissue caused by prolonged pressure, shear, friction, or moisture.
Granulation tissue is new connective tissue and blood vessels that form on the surface of a wound during healing . It is usually dark red or pink in color and moist in appearance . Wound tissue that is firm to palpation may indicate edema, inflammation, or infection . Dry brown eschar is dead tissue that covers the wound and prevents healing . Light yellow exudate is a sign of wound infection or necrosis .
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice a.This response may come across as challenging or confrontational. While the nurse is asking for more information, the phrasing could inadvertently put the client on the defensive. It doesn't validate the client's feelings and may not encourage a productive dialogue.
- Choice b. “Suggesting peer support or mentorship from someone who has gone through a similar experience could be beneficial in some situations, as it may help the client feel less isolated.
- Choice c. “Most people can adjust following this surgery.” may be true, but it does not acknowledge the client’s individual experience and feelings. It may also sound dismissive or minimizing of the client’s challenges.
- Choice d. “You are upset. We can talk about this later.” may be intended to give the client some space, but it does not convey empathy or support. It may also make the client feel rejected or ignored.
Correct Answer is B
Explanation
A 2-g sodium diet means limiting sodium intake to no more than 2000 mg per day. Sodium is found in salt and many processed foods, such as canned vegetables, soups, sauces, and baked goods. Sodium can cause fluid retention and worsen heart failure symptoms, such as shortness of breath, swelling, and fatigue. Therefore, the client should avoid adding salt or salt substitutes (such as baking soda) to their foods and choose fresh or frozen vegetables over canned ones. Lemon juice is a low-sodium alternative that can add flavor to foods without increasing sodium intake.
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