A nurse is assessing a client's wound in the stages of healing. Which of the following areas of the wound represents granulation tissue? (You will find hot spots to select in the artwork below. Select only the hot spot that corresponds to your answer.)
The Correct Answer is "{\"xRanges\":[333.4270782470703,393.4270782470703],\"yRanges\":[222.1666259765625,282.1666259765625]}"
Granulation tissue is a key component of the healing process for wounds and appears as new connective tissue and microscopic blood vessels that form on the surfaces of a wound during the healing process. It typically appears red or pink, indicating the presence of new blood vessels (capillaries). It has a moist, bumpy, or grainy texture. The tissue might look uneven or pebbled. It progressively covers the wound bed, starting from the edges and moving toward the center, eventually filling the wound cavity.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tingling in the toes: Tingling in the toes is not specific to CRPS. It might be a general symptom but is not a classic sign of CRPS.
B. 1+ dorsalis pedis pulse: A weak pulse might indicate reduced circulation but is not specific to CRPS. CRPS is more associated with pain, swelling, and changes in skin color or temperature.
C. Capillary refill of 3 seconds: A capillary refill time of 3 seconds is prolonged and suggests possible circulation issues, but it is not a specific manifestation of CRPS.
D. Increased edema of the foot: Increased edema of the foot is a common manifestation of CRPS. CRPS often presents with localized swelling, along with other symptoms like pain and changes in skin color or temperature.
Correct Answer is D
Explanation
A. "Report a firm ridge below the breasts to the provider." A firm ridge along the bottom curve of the breast can be normal. It’s important to distinguish between normal breast tissue and abnormal lumps. Encouraging clients to report any changes or new lumps to the provider is more appropriate.
B. "Keep your arm relaxed at your side on the side you are examining." The correct technique involves raising the arm on the side being examined to help spread out the breast tissue, making it easier to palpate for lumps and abnormalities.
C. "Use your thumb and forefinger to palpate each breast for lumps." The correct technique involves using the pads of the fingers (not the thumb and forefinger) to palpate the breast in a systematic pattern, such as circular motions or vertical strips, to thoroughly check all areas of the breast.
D. "Use firm pressure to palpate near the area of the ribs and chest wall." Using firm pressure is appropriate for palpating deeper tissues closer to the ribs and chest wall, as this helps detect lumps that may not be superficial.
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