A nurse is assessing a client who has a wound that is healing by primary intention. Which of the following findings should the nurse expect?
Granulation tissue forming at the bottom of the wound bed.
Healing of the wound is prolonged.
Skin edges of the wound are sutured closed.
Wound is contaminated at the time of injury
The Correct Answer is C
A) Granulation tissue forming at the bottom of the wound bed:
Granulation tissue typically forms in wounds that heal by secondary intention. This type of healing occurs when the wound edges are not approximated (e.g., a large or open wound), and new tissue must form to fill the gap. In primary intention healing, the wound edges are well approximated, and granulation tissue is not the hallmark of the healing process, although some may appear early on.
B) Healing of the wound is prolonged:
Wounds healing by primary intention generally heal more quickly than those healing by secondary intention. In primary intention, the wound edges are approximated with sutures, staples, or adhesive, allowing for a faster and more efficient healing process. Therefore, prolonged healing is not expected with primary intention]
C) Skin edges of the wound are sutured closed:
This is the correct finding for a wound healing by primary intention. Primary intention healing occurs when the wound edges are brought together (approximated) and secured with sutures, staples, or adhesive strips. This method promotes faster healing and minimal scarring because the tissue is directly aligned.
D) Wound is contaminated at the time of injury:
Wounds that heal by primary intention are generally clean and not contaminated. If a wound is contaminated or infected at the time of injury, it is more likely to heal by secondary intention, where the tissue must fill in from the base upwards, which takes longer and may result in more scarring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A) Memory loss:
Zolpidem, a sedative-hypnotic commonly prescribed for insomnia, can cause memory problems, including short-term memory loss. This is a known adverse effect of zolpidem, especially when taken in higher doses or when a person is not able to get a full night’s sleep after taking the medication. This side effect can manifest as amnesia or difficulty recalling events that occurred while under the influence of the medication.
B) Dry mouth:
While dry mouth is a common side effect of many medications, including some antihistamines and antidepressants, it is not a typical or major adverse effect associated with zolpidem. Though less common, it may occur in some individuals, but it is not considered a primary or significant adverse effect of this drug.
C) Hypertension:
Zolpidem does not typically cause hypertension. In fact, it is more likely to cause a calming effect that may lead to a decrease in blood pressure, particularly in individuals who experience sedation. It is important for the nurse to monitor for any unusual changes in vital signs, but hypertension is not a known adverse effect of zolpidem.
D) Urinary retention:
Urinary retention is more commonly associated with medications that affect the autonomic nervous system, such as antihistamines, anticholinergics, or certain opioids. Zolpidem is not typically associated with urinary retention. While any sedative could potentially cause mild disruptions in normal bladder function due to its sedative properties, urinary retention is not a frequent or well-known side effect of zolpidem.
Correct Answer is A
Explanation
A) "It sounds like you are exhausted":
This response demonstrates empathy, as the nurse is acknowledging the client's emotional state by reflecting back what the client might be feeling. The nurse recognizes the client's experience of being overwhelmed, using empathetic language to show understanding without judgment or offering solutions prematurely. The phrase "sounds like you are exhausted" is a way of mirroring the client's feelings and giving validation to their experience.
B) "You have so much to deal with. How can I be of help to you?":
While this response offers support and suggests the nurse is ready to help, it does not focus as much on empathy. It is more solution-focused, and while helpful, it doesn’t directly acknowledge or validate the emotional experience of the client as much as an empathetic response would. Empathy focuses on acknowledging the emotional state rather than jumping immediately to offering help.
C) "Tell me more about how you are feeling":
This is a good open-ended question that encourages the client to elaborate on their feelings, but it doesn’t directly reflect empathy. The question prompts the client to talk but does not explicitly acknowledge or validate their emotional experience, which is the primary goal of an empathetic response.
D) "It is impressive how you have managed to deal with this situation":
This response is more focused on offering praise, which, while positive, can come across as dismissive or minimizing of the client's distress. Instead of acknowledging the client's current feelings, it praises their past coping, which may not fully validate the emotional burden they are feeling at the moment. An empathetic response would focus on the client's current emotional state, not necessarily on past strength.
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