A nurse is planning interventions for a client who has a chronic wound on his lower leg. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Apply a moist dressing to the wound

Assess the wound for signs of infection

Debride necrotic tissue from the wound

Elevate the affected leg above the heart level

Massage the wound edges gently

Answer and Explanation

Correct Answer : A,B,C,D

Choice A reason:

Applying a moist dressing to the wound provides a moist environment for wound healing and protects the wound from contamination and trauma. Moisture prevents dehydration and necrosis of the wound bed and promotes cell migration and growth.

Choice B reason:

Assessing the wound for signs of infection is important to detect and treat any infection that may impair wound healing or cause systemic complications. Signs of infection include increased redness, warmth, swelling, pain, drainage, odor, fever, or leukocytosis.

Choice C reason:

Debriding necrotic tissue from the wound is essential to remove any dead or devitalized tissue that may interfere with wound healing or serve as a source of infection. Debridement can be done by surgical, mechanical, enzymatic, or autolytic methods.

Choice D reason:

Elevating the affected leg above the heart level reduces edema and improves blood circulation to the wound. Edema can impair wound healing by causing tissue hypoxia, increasing bacterial growth, and delaying granulation tissue formation.

Choice E reason:

Massaging the wound edges gently is not recommended for chronic wounds, as it may cause trauma or bleeding to the wound bed or delay epithelialization. Massaging may be beneficial for preventing hypertrophic scars or contractures in healed wounds.

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Correct Answer is C

Explanation

Choice A reason:

Type I hypersensitivity is not involved in RA, as it does not involve IgE antibodies or mast cells.

Choice B reason:

Type II hypersensitivity is not involved in RA, as it does not involve IgG or IgM antibodies or target cells.2

Choice C reason:

RA is caused by type III hypersensitivity, which involves the formation and deposition of immune complexes in the synovial membranes of the joints. This triggers complement activation, inflammation, and tissue damage.

Choice D reason:

Type IV hypersensitivity is not involved in RA, as it does not involve cytotoxic T cells or helper T cells.

A. Benign neoplasia of blood cells B. Malignant neoplasia of blood cells C. Benign neoplasia of bone marrow cells D. Malignant neoplasia of bone marrow cells

Correct Answer is D

Explanation

Choice D reason:

Malignant neoplasia of bone marrow cells. Leukemia is a type of cancer that originates from the abnormal and uncontrolled growth of hematopoietic stem cells or progenitor cells in the bone marrow. These cells can proliferate and differentiate into various types of blood cells, such as lymphocytes, granulocytes, monocytes, or erythrocytes. Leukemia can be classified by the type of cell involved (myeloid or lymphoid) and the rate of progression (acute or chronic).

Choice A reason:

Benign neoplasia of blood cells is not a correct term for leukemia, as leukemia is a malignant condition that can invade and destroy normal blood cells and tissues. Benign neoplasia of blood cells is a rare condition that involves the overproduction of normal blood cells, such as polycythemia vera or essential thrombocythemia.

Choice B reason:

Malignant neoplasia of blood cells is not a correct term for leukemia, as leukemia does not originate from blood cells, but from bone marrow cells. Malignant neoplasia of blood cells is a term that can be used for lymphoma, which is a type of cancer that originates from lymphocytes in the lymphatic system.

Choice C reason:

Benign neoplasia of bone marrow cells is not a correct term for leukemia, as leukemia is a malignant condition that can spread to other organs or systems. Benign neoplasia of bone marrow cells is a term that can be used for myelodysplastic syndrome, which is a condition that involves the abnormal development and maturation of bone marrow cells.

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A nurse is planning interventions for a client who has a chronic wound on his lower leg. Which of the following actions should the nurse include in the plan? (Select all that apply.)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has rheumatoid arthritis (RA). The nurse understands that this condition is caused by what type of hypersensitivity?

Correct Answer is C

Explanation

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Correct Answer is D

Explanation

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