A nurse is planning interventions for a client who has a chronic wound on his lower leg. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Apply a moist dressing to the wound

Assess the wound for signs of infection

Debride necrotic tissue from the wound

Elevate the affected leg above the heart level

Massage the wound edges gently

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason:

Applying a moist dressing to the wound provides a moist environment for wound healing and protects the wound from contamination and trauma. Moisture prevents dehydration and necrosis of the wound bed and promotes cell migration and growth.

Choice B reason:

Assessing the wound for signs of infection is important to detect and treat any infection that may impair wound healing or cause systemic complications. Signs of infection include increased redness, warmth, swelling, pain, drainage, odor, fever, or leukocytosis.

Choice C reason:

Debriding necrotic tissue from the wound is essential to remove any dead or devitalized tissue that may interfere with wound healing or serve as a source of infection. Debridement can be done by surgical, mechanical, enzymatic, or autolytic methods.

Choice D reason:

Elevating the affected leg above the heart level reduces edema and improves blood circulation to the wound. Edema can impair wound healing by causing tissue hypoxia, increasing bacterial growth, and delaying granulation tissue formation.

Choice E reason:

Massaging the wound edges gently is not recommended for chronic wounds, as it may cause trauma or bleeding to the wound bed or delay epithelialization. Massaging may be beneficial for preventing hypertrophic scars or contractures in healed wounds.

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Correct Answer is D

Explanation

Choice A reason:

Increased hydrostatic pressure in the portal vein is one factor that causes ascites. The portal vein carries blood from the digestive organs to the liver for processing. However, when the liver is damaged by alcohol abuse, it becomes scarred and fibrotic, creating resistance to blood flow. This results in increased pressure in the portal vein and its branches, which forces fluid out of the capillaries into the abdominal cavity.

Choice B reason:

Decreased oncotic pressure in the plasma is another factor that causes ascites. Oncotic pressure is the force exerted by proteins in the plasma that attracts fluid into the capillaries from the interstitial space. However, when the liver is damaged by alcohol abuse, it cannot produce enough proteins, such as albumin and globulin, which are essential for maintaining oncotic pressure. This results in decreased oncotic pressure in the plasma and increased fluid movement into the interstitial space and the abdominal cavity.

Choice C reason:

Increased aldosterone secretion by the adrenal glands is another factor that causes ascites. Aldosterone is a hormone that regulates the balance of sodium and water in the body. It acts on the kidneys to increase the reabsorption of sodium and water from the urine into the blood. However, when the liver is damaged by alcohol abuse, it cannot metabolize aldosterone properly, leading to its accumulation in the blood. This results in increased sodium and water retention in the body and increased fluid movement into the interstitial space and the abdominal cavity.

Choice D reason:

Ascites is caused by a combination of factors that affect the fluid balance in the abdominal cavity.

A. Atrophy B. Hypertrophy C. Hyperplasia D. Dysplasia

Correct Answer is D

Explanation

Choice A reason:

Atrophy is a decrease in cell size or number in response to adverse stimuli, such as disuse, ischemia, or malnutrition. It does not increase the risk of cancer, but it can impair the function of tissues and organs.

Choice B reason:

Hypertrophy is an increase in cell size in response to normal or abnormal stimuli, such as exercise, hormones, or hypertension. It does not increase the risk of cancer, but it can affect the function of tissues and organs.

Choice C reason:

Hyperplasia is an increase in cell number in response to normal or abnormal stimuli, such as hormones, inflammation, or wound healing. It does not increase the risk of cancer, but it can cause excessive growth of tissues and organs.

Choice D reason:

Dysplasia is an abnormal and potentially reversible change in cell size, shape, and organization in response to persistent stressors. It can be a precursor to cancer if it is not detected and treated early.

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A nurse is planning interventions for a client who has a chronic wound on his lower leg. Which of the following actions should the nurse include in the plan? (Select all that apply.)

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