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 B
Explanation
Choice A rationale:
A stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area.
Choice B rationale:
Unstageable pressure injuries are those where the base of the wound is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.
Choice C rationale:
Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.
Choice D rationale:
A stage 2 pressure injury involves partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.
Correct Answer is A
Explanation
Choice A rationale:
Tertiary intention, also known as delayed primary closure or secondary suture, is a type of wound healing where the wound is initially left open and closed after several days.
Choice B rationale:
The remodeling phase is not a type of wound healing, but a stage of wound healing where the wound fully closes and the new tissue slowly gains strength and flexibility.
Choice C rationale:
Primary intention is a type of wound healing where the wound edges are approximated (brought together) and the wound heals by the process of epithelialization.
Choice D rationale:
Secondary intention is a type of wound healing where the wound is left open and heals by granulation, contraction, and epithelialization.
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