The nurse assesses a deep wound. The area is covered by black and necrotic tissue. What term would the nurse use when documenting this wound?
Blanching
Cellulitis
Tunneling
Eschar
The Correct Answer is D
Choice A reason: Blanching is not the term for black and necrotic tissue. Blanching is the temporary whitening of the skin when pressure is applied. It indicates that the blood flow is intact and the tissue is healthy.
Choice B reason: Cellulitis is not the term for black and necrotic tissue. Cellulitis is a bacterial infection of the skin and subcutaneous tissue. It causes redness, swelling, warmth, and pain in the affected area.
Choice C reason: Tunneling is not the term for black and necrotic tissue. Tunneling is a narrow channel or pathway that extends from the wound into the surrounding tissue. It indicates a deeper and more complex wound.
Choice D reason: Eschar is the term for black and necrotic tissue. Eschar is a thick, dry, and hard crust that forms over a wound. It indicates a severe tissue damage and impaired healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the highest risk client because surgery can cause trauma, blood loss, and infection, which can weaken the immune system and increase the susceptibility to complications. The immune system is the body's defense mechanism that protects against foreign invaders, such as bacteria, viruses, or fungi. Surgery can damage the skin and tissues, which are the first line of defense, and cause inflammation, which can impair the function of the white blood cells, which are the second line of defense. The nurse should monitor the client's vital signs, wound healing, and signs of infection and administer antibiotics, fluids, and pain medication as ordered.
Choice B reason: This is not the highest risk client, but it is a moderate risk client because extreme anxiety can cause stress, which can affect the immune system and increase the vulnerability to illness. Stress is the body's response to a perceived threat or challenge, which can activate the sympathetic nervous system and the hypothalamicpituitaryadrenal (HPA) axis. Stress can cause the release of hormones, such as cortisol and adrenaline, which can suppress the immune system and reduce the production and activity of the white blood cells. The nurse should assess the client's anxiety level and provide coping strategies, such as relaxation, breathing, or counseling.
Choice C reason: This is not the highest risk client, but it is a low risk client because awaiting surgery can cause anxiety, which can affect the immune system and increase the vulnerability to illness. However, the client's anxiety level may not be as high as the client with extreme anxiety, and the client's immune system may not be as compromised as the client who has just had surgery. The nurse should assess the client's anxiety level and provide education, reassurance, and support.
Choice D reason: This is not the highest risk client, but it is a low risk client because delivering a baby can cause blood loss, hormonal changes, and fatigue, which can affect the immune system and increase the risk of infection. However, the client's immune system may not be as compromised as the client who has just had surgery, and the client may have some protection from the antibodies that are passed from the mother to the baby through the placenta and breast milk. The nurse should monitor the client's vital signs, lochia, and signs of infection and provide hygiene, nutrition, and rest.
Correct Answer is C
Explanation
Choice A reason: Popping bursae from standing is not the cause of the grating sound. Bursae are fluidfilled sacs that cushion the joints and reduce friction. Popping bursae may produce a snapping or clicking sound, but not a grating sound.
Choice B reason: A herniated disk in the diseased joint is not the cause of the grating sound. A herniated disk is a condition where the soft inner part of the intervertebral disk bulges out through a tear in the outer layer. A herniated disk may cause pain, numbness, or weakness, but not a grating sound.
Choice C reason: Pieces of bone and cartilage floating is the cause of the grating sound. Osteoarthritis is a degenerative joint disease that causes the breakdown of the cartilage and bone in the joints. Pieces of bone and cartilage may detach and float in the joint space, causing a grating sound when the joint moves.
Choice D reason: Years of an autoimmune process is not the cause of the grating sound. An autoimmune process is a condition where the immune system attacks the body's own tissues. An autoimmune process may cause inflammation, swelling, or damage to the joints, but not a grating sound.
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