An area of erythema on the child's skin is being assessed by the nurse. The nurse presses down on the area, and the area becomes white. What term does the nurse document for this finding?
Blanching
Warmth
Redness
Nonblanching
The Correct Answer is A
Choice A reason: Blanching is the term that the nurse documents for this finding, because it describes the temporary whitening of the skin when pressure is applied. Blanching indicates that the blood vessels in the skin are constricted or compressed, and that the blood flow is reduced or interrupted. Blanching can be a normal response to cold, stress, or pressure, or it can be a sign of a problem, such as ischemia, infection, or inflammation.
Choice B reason: Warmth is not the term that the nurse documents for this finding, because it describes the increased temperature of the skin, not the color change. Warmth indicates that the blood vessels in the skin are dilated or expanded, and that the blood flow is increased or enhanced. Warmth can be a normal response to heat, exercise, or emotion, or it can be a sign of a problem, such as infection, inflammation, or allergy.
Choice C reason: Redness is not the term that the nurse documents for this finding, because it describes the original color of the skin, not the color change. Redness indicates that the blood vessels in the skin are dilated or expanded, and that the blood flow is increased or enhanced, as explained above. Redness can be a normal response to heat, exercise, or emotion, or it can be a sign of a problem, such as infection, inflammation, or allergy.
Choice D reason: Nonblanching is not the term that the nurse documents for this finding, because it describes the opposite of what the nurse observed. Nonblanching means that the skin does not turn white when pressure is applied, but rather remains red or purple. Nonblanching indicates that the blood vessels in the skin are damaged or ruptured, and that the blood has leaked into the surrounding tissues. Nonblanching can be a sign of a serious problem, such as bruising, bleeding, or necrosis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: "I will take all prescribed medications." is not a statement that demonstrates an understanding of the teaching, because it is incomplete and vague. Taking all prescribed medications is an important part of the treatment for HIV, but it does not explain why, how, or for how long the medications are needed. Taking all prescribed medications without understanding the purpose, benefits, or risks can lead to poor adherence, compliance, or outcomes.
Choice B reason: "I will only need to take HIV medications for 6 months, and then I will be cured." is not a statement that demonstrates an understanding of the teaching, because it is incorrect and unrealistic. Taking HIV medications for 6 months is not enough to treat the infection, and there is no cure for HIV. HIV is a chronic and incurable infection that requires lifelong treatment with antiretroviral drugs, which can suppress the viral load, improve the immune function, and prevent the progression to AIDS. Stopping the medications after 6 months can cause the virus to rebound, the immune system to deteriorate, and the disease to worsen.
Choice C reason: "I will have to take medications for the rest of my life." is a statement that demonstrates an understanding of the teaching, because it is accurate and realistic. Taking medications for the rest of one's life is the reality of living with HIV, as there is no cure for the infection. Taking medications for the rest of one's life can help control the infection, maintain the health, and prolong the survival of people with HIV.
Choice D reason: "I will have to be careful and avoid crowds." is not a statement that demonstrates an understanding of the teaching, because it is unnecessary and exaggerated. Being careful and avoiding crowds is not a requirement for people with HIV, as the infection is not transmitted by casual contact, such as touching, hugging, or sharing utensils. Being careful and avoiding crowds can also be detrimental to the social and emotional wellbeing of people with HIV, as it can cause isolation, stigma, or depression.
Correct Answer is A
Explanation
Choice A reason: Inflammatory is the phase of wound healing that occurs at the time of injury and lasts about 35 days, because it is the first and immediate response to tissue damage. Inflammatory is the phase of wound healing that involves the activation of the immune system, the release of chemical mediators, the dilation of blood vessels, the increase of blood flow, the migration of white blood cells, and the formation of a clot. Inflammatory is the phase of wound healing that aims to control bleeding, prevent infection, and prepare the wound for healing.
Choice B reason: Proliferative is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the inflammatory phase and lasts about 23 weeks. Proliferative is the phase of wound healing that involves the growth and multiplication of new cells, the formation of granulation tissue, the synthesis of collagen, the contraction of the wound edges, and the development of epithelial tissue. Proliferative is the phase of wound healing that aims to fill the wound, restore the strength, and cover the defect.
Choice C reason: Maturation is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather the phase of wound healing that occurs after the proliferative phase and lasts about several months to years. Maturation is the phase of wound healing that involves the remodeling and reorganization of the collagen fibers, the reduction of scar tissue, the improvement of elasticity, and the restoration of function. Maturation is the phase of wound healing that aims to refine the wound, enhance the quality, and optimize the outcome.
Choice D reason: Intentional is not the phase of wound healing that occurs at the time of injury and lasts about 35 days, but rather a classification of wound healing that depends on the type and extent of tissue damage, the degree of contamination, and the method of closure. Intentional is a classification of wound healing that refers to wounds that are surgically created, have minimal tissue loss, are clean and sterile, and are closed by primary intention, which means that the wound edges are approximated with sutures, staples, or glue. Intentional is a classification of wound healing that results in faster healing, less scarring, and lower risk of infection.
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