When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:

there is probably a deeper injury than what appears on the surface.

he has lain in one position for such a long time that swelling has occurred.

vessels have dilated and allowed plasma to leak into the wound site.

an infection is in progress at the wound site.

Answer and Explanation

The Correct Answer is C

Choice A rationale:

There is probably a deeper injury than what appears on the surface is incorrect because swelling at the wound site is a normal part of the inflammatory stage of wound healing.

Choice B rationale:

He has lain in one position for such a long time that swelling has occurred is incorrect because swelling at the wound site is a normal part of the inflammatory stage of wound healing.

Choice C rationale:

Vessels have dilated and allowed plasma to leak into the wound site is the correct answer because this is a normal part of the inflammatory stage of wound healing.

Choice D rationale:

An infection is in progress at the wound site is incorrect because while swelling can be a sign of infection, it is also a normal part of the inflammatory stage of wound healing.

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Correct Answer is B

Explanation

Choice A rationale:

A stage 1 pressure injury is characterized by intact skin with non-blanchable redness of a localized area.

Choice B rationale:

Unstageable pressure injuries are those where the base of the wound is covered by slough (yellow, tan, gray, green, or brown) and/or eschar (tan, brown, or black) in the wound bed.

Choice C rationale:

Deep tissue injuries are characterized by a purple or maroon localized area of discolored intact skin or blood-filled blister due to damage of underlying soft tissue from pressure and/or shear.

Choice D rationale:

A stage 2 pressure injury involves partial-thickness loss of dermis presenting as a shallow open ulcer with a red-pink wound bed, without slough.

A. abrasion. B. avulsion. C. hematoma. D. laceration.

Correct Answer is C

Explanation

Choice A rationale:

An abrasion is a superficial injury to the skin caused by scraping or rubbing, which does not match the description of a pooling of blood under unbroken skin.

Choice B rationale:

An avulsion is a wound where a chunk of tissue is torn away, which does not match the description of a pooling of blood under unbroken skin.

Choice C rationale:

A hematoma is a pooling of blood outside of blood vessels, typically caused by trauma. It matches the description of a pooling of blood under unbroken skin.

Choice D rationale:

A laceration is a deep cut or tear in the skin, which does not match the description of a pooling of blood under unbroken skin.

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When the patient complains that he feels he is getting worse because of the increased swelling at his wound site on his leg, the nurse's most helpful response would be that swelling indicates that:

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

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Correct Answer is C

Explanation

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