A nurse is assessing a client who has a pressure injury. Which of the following findings should the nurse expect as an indication the wound is healing?
Dry brown eschar
Wound tissue firm to palpation
Light yellow exudate
Dark red granulation tissue
The Correct Answer is D
A. Dry brown eschar is a sign of necrotic tissue, which indicates that the wound is not healing properly. Eschar needs to be removed for proper healing to occur.
B. Wound tissue firm to palpation is not a typical sign of healing. Healing tissue tends to be softer, while firm tissue could indicate fibrosis or an abnormal healing process.
C. Light yellow exudate can indicate the presence of infection or the early stages of healing, but it is not as specific a sign of healing as granulation tissue. Granulation tissue is a more definitive sign of healing.
D. Dark red granulation tissue is a sign of healthy healing tissue. It consists of new blood vessels and is an indication that the wound is in the proliferative phase of healing, which is a positive sign.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Keep the client's bedroom dark at night is not recommended. People with Alzheimer's disease may experience confusion and disorientation, especially during the night. Keeping the room well-lit can help reduce confusion and improve the client's sense of time.
B. Place a large-face clock in the client's bedroom is a helpful strategy. A large clock can help the client orient themselves to the time of day, which can reduce anxiety and confusion. This is an effective way to help clients with Alzheimer's disease maintain a sense of time and structure.
C. Cover electrical outlets in the client's home with tape is not a necessary safety measure for Alzheimer's disease. While safety is important, the primary focus should be on reducing the risk of falls, confusion, and disorientation. Tape on outlets is not a standard safety recommendation for Alzheimer's patients.
D. Hang a monthly calendar in the client's bedroom is a good idea for some clients, but a calendar may not be as immediately helpful as a clock in the bedroom. While a calendar can help orient the client to the date, a clock is more effective for helping them understand the time of day.
Correct Answer is A
Explanation
A. Applying a lubricating lotion to cracked areas is appropriate for clients with peripheral arterial disease (PAD). This helps to prevent further skin breakdown and maintain skin integrity, which is crucial since clients with PAD have poor circulation and are at risk for ulcers and infections.
B. Resting with feet elevated is not recommended for clients with PAD. Elevating the feet can further reduce blood flow to the lower extremities. Instead, the client should avoid elevating the legs and should consider positioning the feet at heart level or in a dependent position to promote circulation.
C. Soaking feet in hot water is not recommended for clients with PAD because they may have reduced sensation and are at risk for burns. Additionally, hot water can exacerbate circulation problems and increase the risk of injury.
D. Using a heating pad is not recommended for clients with PAD because they may have impaired sensation in their feet. The heating pad could cause burns or other injuries due to the lack of feeling in the affected areas.
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