A nurse is assessing a client's healed wound and notes the formation of hard, raised fibrous tissue. How should the nurse document this finding?

Rationale:

A. Decreased range of motion in the affected limb is correct. Contractures are permanent shortening of muscles, tendons, or ligaments that often develop after burn injuries, particularly when deep partial-thickness or full-thickness burns heal with significant scar tissue formation. As scar tissue forms and contracts, it limits joint mobility, leading to restricted range of motion, functional impairment, and deformity. Early recognition and intervention, such as physical therapy, splinting, and proper positioning, are essential to prevent or minimize contractures.

B. Increased muscle strength in the affected limb is incorrect. Contractures result in limited movement and stiffness, not enhanced muscle strength. An increase in strength would suggest recovery and rehabilitation rather than a complication of scarring.

C. Improved flexibility and joint movement is incorrect. Contractures reduce flexibility and impede joint movement. Improved flexibility would indicate successful healing and rehabilitation, not the development of a contracture.

D. Swelling and redness around the burn area is incorrect. While swelling and erythema may occur during the acute inflammatory phase of burn healing, they do not specifically indicate contracture formation. Contractures develop over time as scar tissue matures and tightens, rather than during initial inflammation.

Rationale:

A. The Loop of Henle primarily functions to concentrate urine and maintain the osmotic gradient in the renal medulla. It allows for selective reabsorption of water and salts but does not directly filter blood. Its role is in modifying the filtrate that has already been produced by the glomerulus rather than initiating filtration.

B. The proximal convoluted tubule is responsible for reabsorbing the majority of filtered water, glucose, amino acids, and electrolytes from the glomerular filtrate back into the bloodstream. While it plays a crucial role in regulating the composition of the filtrate, it does not perform the initial filtration of blood.

C. The glomerulus is a tuft of specialized capillaries located within Bowman's capsule in the nephron, and it serves as the primary filtration unit of the kidney. Blood enters the glomerulus under high hydrostatic pressure, which forces water, electrolytes, glucose, and small molecules through the glomerular filtration membrane into Bowman's capsule, forming the initial filtrate. The filtration membrane is selective, retaining larger molecules like proteins and blood cells within the circulatory system. This process establishes the foundation for urine formation and allows the kidneys to regulate fluid and electrolyte balance effectively.

D. The collecting duct primarily functions in the final concentration or dilution of urine, responding to hormones such as antidiuretic hormone (ADH) and aldosterone. It fine-tunes water and electrolyte reabsorption but does not participate in the initial filtration of blood.