A nurse is evaluating a patient who has a stage 1 pressure injury. What findings should the nurse anticipate?

Choice A rationale

Glaucoma is a condition that damages the eye’s optic nerve and can result in vision loss and blindness. However, it doesn’t cause a cloudy, opaque area over the lens of the eye.

Choice B rationale

Diabetic retinopathy is a diabetes complication that affects eyes. It’s caused by damage to the blood vessels of the light-sensitive tissue at the back of the eye (retina). But it doesn’t cause a cloudy, opaque area over the lens of the eye.

Choice C rationale

Macular degeneration is a medical condition which may result in blurred or no vision in the center of the visual field. But it doesn’t cause a cloudy, opaque area over the lens of the eye.

Choice D rationale

A cataract is a clouding of the lens in the eye that affects vision. Cataracts are very common in older people. Symptoms of cataracts include cloudy or blurry vision.

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.