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A contusion, commonly known as a bruise, is characterized by skin discoloration due to trauma that causes bleeding under the skin. It does not result in a raised scar, which is why it is not the correct term to describe the patient's condition.

A laceration refers to a deep cut or tear in the skin or flesh. Because the nurse is assessing a scar, not a fresh wound, laceration is not the appropriate term for documentation.

A hematoma is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This term would not be used to describe a raised scar, making it an incorrect choice for documentation.

Cleaning directly over the wound with a swab could be harmful as it may disrupt the healing tissue. This method does not follow the principles of medical asepsis, which aim to reduce the risk of infection and promote wound healing.

Cleaning from the outer abdomen toward the wound could potentially bring contaminants from the less clean abdomen into the sterile area of the wound. This would increase the risk of infection and is not the recommended practice.

Swabbing from one side to the other across the wound does not ensure that contaminants are moved away from the wound area. It could spread bacteria across the surface, which is not conducive to proper wound care.

Applying hydrocolloids to the wound bed is not a form of mechanical debridement. Hydrocolloids are dressings that provide a moist environment and promote autolytic debridement but do not mechanically remove necrotic tissue.

Using a topical enzyme solution in the wound bed is a chemical, not mechanical, method of debridement. Enzymatic debridement uses proteolytic enzymes to break down necrotic tissue without affecting viable tissue.

Placing a transparent dressing over the pressure injury is not a form of debridement. Transparent dressings allow for oxygen exchange and protect the wound from infection, but they do not debride the wound.

Healing by secondary intention occurs when a wound is left open and closes naturally through granulation tissue formation, contraction, and epithelialization. This process is typically for wounds that cannot be closed with sutures due to infection or other factors.

The remodeling phase is the final stage of the healing process where the wound strength increases and scar tissue forms. It is not a type of wound healing but rather a phase that can occur in both primary and secondary intention healing.

Tertiary intention, also known as delayed primary closure, involves initially leaving the wound open due to contamination or infection and then closing it surgically once it is clean. This is not the type of healing described in the question.

Hydrocolloid dressings are not designed to keep a wound dry; instead, they maintain a moist environment which is conducive to wound healing. They absorb exudate and form a gel, which promotes granulation and epithelialization.

The primary purpose of a hydrocolloid dressing is to remain in place for an extended period, typically up to 7 days. This minimizes disturbance to the wound, reduces the risk of infection, and maintains a moist healing environment.

While hydrocolloid dressings can help prevent bacterial growth due to their occlusive nature, their main function is not to destroy microorganisms. They provide a barrier against external contaminants and support autolytic debridement.

A headache is a nonspecific symptom and can be associated with many conditions. It is not typically indicative of internal hemorrhage, which is more likely to present with hemodynamic changes.

While a rising pulse is a sign of internal hemorrhage due to the body’s attempt to maintain cardiac output, the blood pressure would typically fall, not rise, as the blood volume decreases.

Lethargy and a falling pulse are signs of decreased cardiac output, but in the case of internal hemorrhage, the blood pressure would usually fall, not rise, due to the loss of blood volume.

Elastic adhesive tape is not the best option for a patient experiencing skin irritation from tape removal because it may cause further irritation when removed.

Karaya paste is primarily used as a skin barrier and adhesive for ostomy appliances, not for securing dressings, especially in cases of skin irritation.

Paper tape is less irritating to the skin than elastic adhesive tape, but it still requires removal with each dressing change, which can irritate sensitive skin.

Preparing a discard bag next to the wound is a practical step in the process, but it is not the most critical action to prevent infection.

Remaining very still during the procedure is important, but it does not directly relate to maintaining the sterility of the dressing change.

Restraining from moving the patient is not typically necessary unless the patient is at risk of causing harm to themselves or disrupting the procedure.