A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full-thickness wound with jagged edges and muscle tissue visible after a biking accident. The nurse should document this as which of the following types of wounds?
Unintentional closed wound
Intentional closed wound
Intentional open wound
Unintentional open wound
The Correct Answer is D
Choice A rationale: Unintentional closed wounds involve blunt force trauma but do not typically result in jagged edges with muscle tissue visible.
Choice B rationale: Intentional closed wounds are typically surgical incisions and do not present with jagged edges and visible muscle tissue.
Choice C rationale: Intentional open wounds are typically surgical incisions, not the result of a biking accident.
Choice D rationale: Unintentional open wounds result from accidents and can present with jagged edges and visible tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale: While dietary fiber is important for bowel health, raw vegetables can be harder to digest. Cooking or steaming vegetables may be a more suitable option for some individuals with constipation.
Choice B rationale: Limiting activity can contribute to constipation, as physical activity helps stimulate bowel movements.
Choice C rationale: Drinking four to five glasses of water daily is important for maintaining hydration and supporting normal bowel function. Dehydration can contribute to constipation.
Choice D rationale: Bearing down hard when defecating may increase the risk of complications and is not a recommended strategy for relieving constipation.
Correct Answer is B
Explanation
Choice A rationale: Elevating the head of the bed is not the recommended action when moving a client up in bed.
Choice B rationale: Having the client fold the arms across the chest is not the primary action when moving a client up in bed.
Choice C rationale: Asking another nurse about the plan of care is not necessary in this situation and does not directly address the action needed when moving the client.
Choice D rationale: Maintaining a pillow under the client's head helps provide comfort and support during the movement.
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