Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

Hemostasis

Inflammatory phase

Maturation phase

Proliferation phase

Answer and Explanation

The Correct Answer is D

Choice A rationale: Hemostasis is the initial phase of wound healing that involves vasoconstriction and clot formation to control bleeding.
Choice B rationale: The inflammatory phase involves the removal of debris and the influx of inflammatory cells to the wound site.
Choice C rationale: The maturation phase is characterized by the remodeling of collagen and scar formation.
Choice D rationale: Granulation tissue formation and easy bleeding during wound care are characteristic of the proliferation phase, which involves tissue repair and regeneration.

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Correct Answer is A

Explanation

Choice A rationale: Overflow incontinence is characterized by a constant leakage of small amounts of urine and a distended, palpable bladder due to incomplete emptying. This is consistent with the client's symptoms.
Choice B rationale: Reflex incontinence is associated with neurologic dysfunction but does not typically involve constant leakage.
Choice C rationale: Stress incontinence is associated with increased intra-abdominal pressure and typically involves leakage with activities like coughing or sneezing.
Choice D rationale: Urge incontinence is characterized by a sudden, strong urge to void and is not typically associated with constant leakage.

A. Deep Tissue Injury B. Stage III Pressure Ulcer C. Unstageable Ulcer D. Stage IV Pressure Ulcer

Correct Answer is A

Explanation

Choice A rationale: A deep tissue injury involves intact skin with a purple or maroon localized area of discolored, non-blanchable, deep red or maroon, or a blood-filled blister due to damage of underlying soft tissue from pressure or shear. It is a stage that is more appropriate for the described wound involving the epidermis and dermis.
Choice B rationale: Stage III pressure ulcers involve full-thickness tissue loss, but they do not involve the epidermis and dermis.
Choice C rationale: Unstageable ulcers are covered with slough or eschar, making it difficult to determine the depth of tissue involvement. In this case, the wound's description indicates involvement of the epidermis and dermis.
Choice D rationale: Stage IV pressure ulcers involve full-thickness tissue loss with exposed bone, tendon, or muscle, not just the epidermis and dermis.

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Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?

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Naxlex Comprehensive Predictor Exams

A nurse assessing a client notes that the client has a constant leakage of small amounts of urine and a bladder that is distended and palpable. The nurse should associate these findings with which of the following types of urinary incontinence?

Correct Answer is A

Explanation

A nurse is completing a chart audit and finds the following wound documented as a Stage I Pressure Ulcer. The nurse recognizes this is incorrect. How should the wound have been classified?

Correct Answer is A

Explanation

A nurse working in long-term care facility is assessing residents at risk for the development of a pressure injury. Which resident would be most at risk?

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Upon assessment of a client's wound, the nurse notes the formation of granulation tissue. The tissue bleeds easily when the nurse performs wound care. What is the phase of wound healing characterized by the nurse's assessment?