A nurse is performing skin assessments for a group of clients. Which of the following images indicates a wound that is healing by secondary intention?
A: Circular Red Area
B: Bruise on Leg
C: Sutured Incision (Primary intention)
D: Open Ulcer/Pressure Injury (Secondary Intention)
The Correct Answer is D
Rationale:
A. Circular Red Area: This is a Stage 1 Pressure Injury (non-blanchable erythema or shallow ulcer).
B. Bruise on Leg: This shows contusion/bruising (ecchymosis) and possible swelling, which is a closed injury, not an open wound that requires healing by intention.
C. Sutured Incision (Primary intention): The wound edges are cleanly approximated (brought together) with sutures, staples, or adhesive. Minimal tissue loss occurred. Healing occurs rapidly, with minimal granulation tissue and minimal scarring. The image showing the clean, surgical incision closed with staples or sutures.
D. Open Ulcer/Pressure Injury (Secondary Intention): The wound has significant tissue loss, irregular borders, and the edges cannot be approximated (closed). The wound is left open to heal by granulation (formation of new connective tissue) from the bottom up. This process is slower and results in a larger, more noticeable scar.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale
A. Sublimation: Sublimation involves channeling unacceptable impulses into socially acceptable or constructive activities, such as exercising or creating art. Smoking to manage anxiety does not transform the impulse into a positive behavior, so this does not fit.
B. Projection: Projection occurs when an individual attributes their own unacceptable feelings or impulses onto someone else. The client is not blaming others for their anxiety or behavior, so projection is not demonstrated here.
C. Rationalization: Rationalization involves justifying behaviors with seemingly logical reasons to avoid confronting the true underlying feelings. The client explains smoking as a way to manage anxiety, providing a rational explanation for a behavior that may have deeper psychological or habitual roots.
D. Dissociation: Dissociation involves disconnecting from reality or separating oneself from thoughts, feelings, or identity. The client remains aware of their behavior and feelings, so dissociation is not applicable in this scenario.
Correct Answer is B
Explanation
Rationale
A. Place the client in a supine position: Placing a client supine is not necessary for restraint use and may increase the risk of aspiration, especially in a client with a PEG tube. Positioning should prioritize safety and comfort, typically semi-Fowler’s for feeding.
B. Remove the restraints every 2 hr: Restraints must be removed at least every 2 hours to assess skin integrity, circulation, range of motion, and the client’s need for continued restraint. Regular release prevents complications such as skin breakdown, nerve injury, or impaired circulation.
C. Secure the straps with a square knot: Restraint straps should be secured using a quick-release knot, not a square knot, to allow rapid removal in an emergency. Using an incorrect knot can delay urgent intervention and compromise safety.
D. Attach the straps to the side rails of the bed frame: Restraints should be attached to the bed frame not the side rails that move, or another fixed point, to prevent injury. Attaching to movable side rails can cause entrapment or worsen injury if the rails are raised or lowered.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today