A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full-thickness wound with jagged edges and muscle tissue visible after a biking accident. The nurse should document this as which of the following types of wounds?

Unintentional closed wound

Intentional closed wound

Intentional open wound

Unintentional open wound

Answer and Explanation

The Correct Answer is D

Choice A rationale: Unintentional closed wounds involve blunt force trauma but do not typically result in jagged edges with muscle tissue visible.
Choice B rationale: Intentional closed wounds are typically surgical incisions and do not present with jagged edges and visible muscle tissue.
Choice C rationale: Intentional open wounds are typically surgical incisions, not the result of a biking accident.
Choice D rationale: Unintentional open wounds result from accidents and can present with jagged edges and visible tissue.

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Correct Answer is A

Explanation

Choice A rationale: Voiding and discarding the urine is the first step in a 24-hour urine collection to ensure that the collection starts with a fresh specimen.
Choice B rationale: Adding the first voiding to the specimen is not the correct initial step.
Choice C rationale: Keeping the urine warm during collection is important, but it is not the first step in the process.
Choice D rationale: Beginning the collection at a specific time is part of the process but not the initial step.

A. "You are experiencing stress incontinence. Do you know how to do Kegel exercises?" B. "You are experiencing transient incontinence. Have you been administered diuretics or IV fluids lately?" C. "You are experiencing total incontinence. Have you had any surgeries or trauma that may be causing this?" D. "You are experiencing reflex incontinence. Have you had a spinal cord injury in the past?"

Correct Answer is D

Explanation

Choice A rationale: Stress incontinence is characterized by involuntary urine leakage during activities that increase intra-abdominal pressure, such as coughing or sneezing.
Choice B rationale: Transient incontinence is temporary and often related to factors like medications or medical conditions.
Choice C rationale: Total incontinence refers to continuous and unpredictable leakage of urine.
Choice D rationale: Reflex incontinence is associated with neurologic dysfunction, and the lack of warning or stress preceding involuntary urination aligns with this description.

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A nurse working in an emergency room is assessing a client who has a leg wound. The nurse notes a full-thickness wound with jagged edges and muscle tissue visible after a biking accident. The nurse should document this as which of the following types of wounds?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is initiating a 24-hour urine collection for a client at home. What will be the first thing the nurse will ask the client to do at the beginning of the specimen collection?

Correct Answer is A

Explanation

Reflex incontinence is associated with neurologic dysfunction and occurs when no warning or stress precedes periodic involuntary urination.

Correct Answer is D

Explanation

A nurse is caring for a client who has urinary incontinence. Which of the following actions should the nurse implement to prevent the development of skin breakdown?

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