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?

Choice A reason: Stage 4 is the remodeling stage of bone healing, which occurs from 6 to 12 weeks after the fracture. In this stage, the callus, which is a mass of fibrous tissue and cartilage that forms around the fracture site, is gradually resorbed and replaced by mature bone. The bone becomes stronger and more compact and regains its original shape and function.

Choice B reason: Stage 3 is the callus formation stage of bone healing, which occurs from 2 to 6 weeks after the fracture. In this stage, the granulation tissue, which is a soft tissue that fills the fracture gap, is replaced by a callus that bridges the fracture ends. The callus is composed of fibroblasts, chondroblasts, and osteoblasts that produce collagen, cartilage, and bone matrix. The callus stabilizes the fracture and prepares it for remodeling.

Choice C reason: Stage 5 is not a valid stage of bone healing. There are only four stages of bone healing: stage 1 is the inflammatory stage, stage 2 is the reparative stage, stage 3 is the callus formation stage, and stage 4 is the remodeling stage.

Choice D reason: Stage 1 is the inflammatory stage of bone healing, which occurs from the time of the fracture to 3 to 5 days after the fracture. In this stage, the blood vessels around the fracture site are ruptured and form a hematoma, which is a blood clot that surrounds the fracture ends. The hematoma triggers an inflammatory response that involves the release of cytokines, growth factors, and inflammatory cells that initiate the healing process. The hematoma also provides a scaffold for the granulation tissue to grow.

Choice A reason: This is not the priority assessment because peripheral edema is not a lifethreatening complication of immobility. Peripheral edema is the swelling of the lower extremities due to fluid accumulation. It can be caused by various factors, such as venous insufficiency, heart failure, kidney disease, or medication side effects. The nurse should monitor the client's fluid status and provide elevation and compression therapy as needed.

Choice B reason: This is the priority assessment because lung sounds can indicate the presence of respiratory complications, such as pneumonia or atelectasis, which are common and serious consequences of immobility. Pneumonia is an infection of the lungs that causes inflammation, mucus production, and impaired gas exchange. Atelectasis is the collapse of alveoli, which are the tiny air sacs in the lungs that facilitate oxygen and carbon dioxide exchange. The nurse should auscultate the client's lung sounds regularly and report any abnormal findings, such as crackles, wheezes, or diminished breath sounds. The nurse should also encourage the client to cough, deep breathe, and use incentive spirometry to prevent or treat respiratory problems.

Choice C reason: This is not the priority assessment because bowel sounds can reflect the status of the gastrointestinal system, which is not directly affected by immobility. Bowel sounds are the noises produced by the movement of food and gas through the intestines. They can vary in frequency and intensity depending on the client's diet, activity, and medications. The nurse should auscultate the client's bowel sounds and assess for any signs of constipation, diarrhea, or obstruction. The nurse should also promote the client's bowel function by providing adequate hydration, fiber, and laxatives as ordered.

Choice D reason: This is not the priority assessment because skin turgor can indicate the level of hydration, which is not a primary concern of immobility. Skin turgor is the elasticity of the skin that allows it to return to its normal shape after being pinched or pulled. It can be affected by factors such as age, weight loss, dehydration, or edema. The nurse should assess the client's skin turgor and provide adequate fluids and electrolytes as needed. The nurse should also pay attention to the client's skin integrity and prevent or treat any pressure ulcers or wounds that may result from immobility.