What phase of wound healing occurs at the time of injury and lasts about 35 days?

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.

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.