A nurse is educating a client about why they are able to feel a hard lump over the site of the injury. Which client statement indicates an understanding of the teaching?
That lump will need to be watched. It might become cancerous.
That lump is an indication that I have a clotting disorder and I need to follow up with a hematologist.
When I injured myself, there was a gap in those muscle fibers and that allowed blood to accumulate.
I can expect to have that lump for the rest of my life. It will never go away.
The Correct Answer is C
Choice A reason: A traumatic hematoma or muscle contusion is a localized collection of extravasated blood within tissues resulting from vascular disruption. It is a benign inflammatory and reparative response to trauma, not a neoplastic process; therefore, suggesting it might become cancerous demonstrates a fundamental misunderstanding of the etiology of trauma-induced tissue lesions.
Choice B reason: While hematoma formation involves blood, it occurs as a local response to blunt force trauma that tears small blood vessels. It is not an indicator of a systemic coagulopathy or hematological disorder in the absence of other symptoms such as spontaneous bruising, petechiae, or excessive gingival bleeding.
Choice C reason: When blunt trauma causes a muscle tear or disruption in the myofibrillar architecture, the resulting damage to local vasculature leads to the extravasation of blood into the interstitial spaces. This hematoma initially feels firm or "hard" as the blood pools and begins to coagulate within the limited space of the muscle compartment.
Choice D reason: Hematomas are dynamic, self-limiting lesions. Over time, the body initiates a resorption process where macrophages and other inflammatory cells break down the coagulated blood and heme products. Most traumatic hematomas resolve spontaneously through this physiological remodeling, meaning the assertion that the lump is permanent is clinically incorrect.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: A bounding, 4+ pulse is a high-amplitude, forceful pulse often associated with hyperdynamic states, fluid overload, or aortic insufficiency. This finding is easily palpable, so there is absolutely no clinical indication to use a Doppler, as the pulse is clearly present and clinically significant at a high magnitude.
Choice B reason: A normal 2+ pulse is the expected clinical finding. If a pulse is palpable at a 2+ grade, it indicates adequate distal perfusion to that extremity. A Doppler instrument is not indicated for a standard, healthy pulse, as it is designed to detect pulses that are not detectable by manual palpation alone.
Choice C reason: A thready or weak pulse suggests poor cardiac output or peripheral arterial disease. When a peripheral pulse is so weak that it cannot be accurately felt or graded by palpation, the nurse must use a handheld Doppler device to verify the presence, character, and location of blood flow.
Choice D reason: While capillary refill time is an important indicator of tissue perfusion, a delay in this time indicates microvascular circulation issues, not necessarily the status of the major peripheral arteries. Comparing refill times is a standard assessment that does not inherently dictate the use of a Doppler.
Correct Answer is D
Explanation
Choice A reason: Skeletal muscle is responsible for voluntary body movements and is attached to the skeleton via tendons. It is innervated by the somatic nervous system, which allows for conscious control of contractions, making it entirely inappropriate for the involuntary, peristaltic functions required by the gastrointestinal tract.
Choice B reason: Cardiac muscle is a specialized type of involuntary, striated muscle found exclusively in the heart. While it functions involuntarily, it possesses unique structural properties, such as intercalated discs, specifically designed to synchronize the contraction of the myocardium, and it does not exist within the gastrointestinal system.
Choice C reason: Striated muscle is a classification that includes both skeletal and cardiac muscle, characterized by a microscopic pattern of alternating light and dark bands. The gastrointestinal tract relies on non-striated, involuntary muscle tissue, meaning the classification of striated muscle does not apply to the majority of the digestive tract.
Choice D reason: Smooth muscle is non-striated, involuntary muscle found in the walls of hollow organs, including the esophagus, stomach, and intestines. Its structural properties allow it to undergo slow, sustained contractions, which are essential for generating the rhythmic peristaltic waves required to move food through the gastrointestinal tract.
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