A client has a wound on the lower leg that is covered with dry, yellow crusts. The nurse recognizes this as an indication of:
Slough
Eschar
Granulation tissue
Epithelial tissue
The Correct Answer is A
Answer: A.
Slough is dead tissue that is shed from the surface of the wound. It may be white, yellow, green, or brown in color and may have a soft, moist, or dry texture. It should be removed to promote wound healing.
B. Eschar is dead tissue that adheres to the surface of the wound. It may be black, brown, or tan in color and may have a hard, dry, or leathery texture. It may act as a natural barrier to infection in some cases, but it may also impair wound healing and circulation in others.
C. Granulation tissue is new tissue that forms in the base of the wound during healing. It is red or pink in color and has a shiny, moist, granular appearance. It indicates healthy wound healing and should be protected from trauma or infection.
D. Epithelial tissue is new tissue that forms over the granulation tissue during healing. It is pink or pale in color and has a thin, smooth, translucent appearance. It indicates the final stage of wound healing and should be moisturized and protected from sun exposure.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Answer: A
Primary intention is a type of wound healing that occurs when the edges of the wound are well approximated and there is minimal tissue loss or infection. It results in minimal scarring and fast healing.
B. Secondary intention is a type of wound healing that occurs when the edges of the wound are not approximated or there is extensive tissue loss or infection. It results in granulation tissue formation, contraction, and epithelialization. It takes longer to heal and may result in scarring and infection.
C. Tertiary intention is a type of wound healing that occurs when there is a delay in closing the wound or when the wound is intentionally left open for drainage or debridement. It results in less scarring than secondary intention but more than primary intention.
D. Quaternary intention is not a valid term for wound healing.
Correct Answer is A
Explanation
Answer: A
To reduce edema and venous pressure is the rationale for elevating the leg above the level of the heart whenever possible. Venous ulcers are caused by chronic venous insufficiency, which impairs venous return and causes blood pooling, increased venous pressure, and edema in the lower extremities. Elevation helps to facilitate venous return and reduce edema and venous pressure, which improves wound healing.
B. To increase arterial blood flow and oxygenation is not the rationale for elevating the leg above the level of the heart whenever possible. Arterial ulcers are caused by arterial insufficiency, which impairs arterial blood flow and oxygenation to the lower extremities. Elevation may worsen arterial blood flow and oxygenation, as it reduces the effect of gravity on arterial perfusion.
C. To prevent infection and inflammation is not the rationale for elevating the leg above the level of the heart whenever possible. Infection and inflammation are complications of venous ulcers, but they are not directly affected by elevation. Infection and inflammation are prevented by proper wound care, such as cleansing, dressing, debridement, and antibiotic therapy.
D. To stimulate nerve regeneration and sensation doesn’t help with venous ulcers.
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