A nurse in a long-term care facility is caring for a client who had abdominal surgery 6 weeks ago.
Which of the following images indicates the client's wound is healing by primary intention?

The wound has edges that are well-approximated.

The wound shows signs of granulation tissue formation.

The wound has a scab covering the surface.

The wound is oozing serous drainage.

Answer and Explanation

The Correct Answer is A

Choice A rationale

Healing by primary intention occurs when wound edges are approximated, promoting direct tissue regeneration. This process minimizes scarring and involves epithelial cell migration and collagen synthesis.

Choice B rationale

Granulation tissue formation is characteristic of secondary intention healing. In this method, wounds heal from the base upward, requiring granulation tissue to fill the wound bed before epithelialization occurs.

Choice C rationale

Scab formation indicates that healing is in progress but does not specifically represent primary intention. Scabs form during secondary or tertiary healing phases to protect the underlying tissue.

Choice D rationale

Serous drainage is associated with the inflammatory phase of wound healing and does not signify primary intention. Excessive drainage may indicate impaired healing or infection.

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Correct Answer is A

Explanation

Choice A rationale

Cracks at the corners of the mouth, or cheilosis, are often associated with nutritional deficiencies like iron or vitamin B deficiencies. Monitoring for these cracks helps diagnose and treat the underlying condition.

Choice B rationale

A reddened tongue is typically associated with vitamin B12 deficiency or other conditions but not cheilosis. It can help identify a different deficiency or condition.

Choice C rationale

Pale conjunctiva is an indicator of anemia but does not specifically correlate with cheilosis. It suggests reduced hemoglobin levels due to iron deficiency.

Choice D rationale

Brittle fingernails may result from chronic iron deficiency anemia but are not directly related to cheilosis. They serve as additional evidence of prolonged anemia.

A. Tingling of the fingers. B. Serosanguineous drainage on the dressing. C. Report of sore throat. D. Soreness at the incision site.

Correct Answer is A

Explanation

Choice A rationale

Tingling indicates hypocalcemia due to parathyroid gland injury, a complication of thyroidectomy. Hypocalcemia arises when parathyroid hormone secretion decreases, impairing calcium homeostasis. Normal serum calcium ranges are 8.5–10.2 mg/dL.

Choice B rationale

Serosanguineous drainage is normal wound exudate consisting of serum and red blood cells. It reflects standard postoperative healing, provided there is no excessive volume or purulent drainage suggesting infection.

Choice C rationale

Sore throat is expected due to endotracheal intubation during anesthesia. Transient inflammation resolves spontaneously without clinical intervention.

Choice D rationale

Incisional soreness is typical and does not suggest complications. It results from tissue disruption during surgery and should subside as healing progresses.

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A nurse in a long-term care facility is caring for a client who had abdominal surgery 6 weeks ago.Which of the following images indicates the client's wound is healing by primary intention?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a client who has iron-deficiency anemia.Which of the following should the nurse monitor for the clinical manifestation of cheilosis?

Correct Answer is A

Explanation

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Correct Answer is A

Explanation

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A nurse in a long-term care facility is caring for a client who had abdominal surgery 6 weeks ago.
Which of the following images indicates the client's wound is healing by primary intention?