A nurse is assessing a patient who has a wound that is healing by first intention. What findings should the nurse expect?
Granulation tissue forming at the bottom of the wound bed.
Wound was contaminated at the time of injury.
Healing of the wound is prolonged.
Skin edges of the wound are sutured closed.
The Correct Answer is D
Choice A rationale
Granulation tissue forming at the bottom of the wound bed is a characteristic of secondary intention healing, not primary intention. In secondary intention, the wound is left open and fills with granulation tissue.
Choice B rationale
A wound that was contaminated at the time of injury would likely require secondary intention healing to allow for cleaning and observation of the wound. This is not typical of primary intention healing.
Choice C rationale
Prolonged healing of the wound is not a characteristic of primary intention healing. In primary intention, the wound edges are brought together (approximated), which allows for rapid healing.
Choice D rationale
In primary intention healing, the skin edges of the wound are sutured closed. This is the most distinctive feature of primary intention healing, as it allows for minimal scar formation and quick healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Vibration of the eardrum is not directly transmitted to the eighth cranial nerve, bypassing the inner ear structures. The vibrations from the eardrum are first transmitted through the ossicles (tiny bones in the middle ear) to the cochlea in the inner ear.
Choice B rationale
Sound waves enter the ear canal, but they are not directly converted to electrical impulses. The sound waves cause the eardrum to vibrate, and these vibrations are transmitted through the ossicles to the cochlea, where they are converted into electrical signals that are sent to the brain via the eighth cranial nerve.
Choice C rationale
Vibration of the eardrum transmits through the bony ossicles to the perilymph in the inner ear, stimulating the eighth cranial nerve. This is the correct description of the process of hearing.
Choice D rationale
Sound is not transmitted directly from the eardrum to the brain. The sound-induced vibrations of the eardrum are transmitted through the ossicles to the cochlea, where they are converted into electrical signals that are sent to the brain via the eighth cranial nerve.
Correct Answer is AANDD
Explanation
Choice A rationale
An ileostomy involves creating a stoma, or opening, in the abdominal wall. The location of the stoma is typically in the right lower abdomen.
Choice B rationale
The end of the stoma should not be painful after the procedure. If the patient experiences pain, it could indicate a complication and should be reported to the healthcare provider.
Choice C rationale
The patient should not expect the stoma to be a purple color. A healthy stoma should be red or pink. A purple stoma could indicate a lack of blood flow, which is a serious issue that needs immediate medical attention.
Choice D rationale
After an ileostomy, the patient will have liquid or semi-liquid stool pass through the stoma. This is because the large intestine, which normally absorbs water and forms solid stool, is bypassed or removed in the procedure.
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