A patient has a pooling of blood under unbroken skin of the hip after a fall.
The nurse should document that this patient has a(n):
abrasion.
avulsion.
hematoma.
laceration.
The Correct Answer is C
Choice A rationale:
An abrasion is a superficial injury to the skin caused by scraping or rubbing, which does not match the description of a pooling of blood under unbroken skin.
Choice B rationale:
An avulsion is a wound where a chunk of tissue is torn away, which does not match the description of a pooling of blood under unbroken skin.
Choice C rationale:
A hematoma is a pooling of blood outside of blood vessels, typically caused by trauma. It matches the description of a pooling of blood under unbroken skin.
Choice D rationale:
A laceration is a deep cut or tear in the skin, which does not match the description of a pooling of blood under unbroken skin.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Reconstruction is incorrect because it is not the second stage of wound healing.
Choice B rationale:
Maturation is incorrect because it is not the second stage of wound healing.
Choice C rationale:
Proliferation is incorrect because it is not the second stage of wound healing.
Choice D rationale:
Inflammation is the correct answer because it is the second stage of wound healing.
Correct Answer is B
Explanation
Choice A rationale:
Asking someone to quickly get an abdominal binder is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position to prevent further injury.
Choice B rationale:
Assisting the patient to a supine position is the correct action. This is because the patient’s statement may indicate dehiscence (separation of the wound edges), and placing the patient in a supine position with the knees bent can reduce tension on the wound and prevent further injury.
Choice C rationale:
Seating the patient in a nearby chair is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.
Choice D rationale:
Instructing the patient to pant to reduce abdominal tension is not the immediate action. The nurse should first ensure the patient’s safety by assisting them to a supine position.
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