For the client with obstructive sleep apnea (OSA), the nurse should expect the following findings:

The correct answer is: a. Edema.

Choice A: Edema

Edema is swelling caused by excess fluid trapped in the body’s tissues. It is a common sign of inflammation and infection. When a wound becomes infected, the body’s immune response can cause increased fluid accumulation in the affected area, leading to noticeable swelling. This swelling is often accompanied by redness, warmth, and pain, which are classic signs of infection.

Choice B: Petechiae

Petechiae are small, red or purple spots caused by bleeding into the skin. They are not typically associated with wound infections but rather with conditions that cause bleeding or clotting disorders. Petechiae do not indicate an infection but rather a different underlying issue that may require further investigation.

Choice C: Urticaria

Urticaria, also known as hives, is a skin reaction that causes itchy welts. It is usually a result of an allergic reaction and is not a sign of wound infection. Urticaria is characterized by raised, red, itchy bumps on the skin and does not typically occur in response to an infected wound.

Choice D: Crusting over granulated tissue

Crusting over granulated tissue is a normal part of the wound healing process. Granulation tissue forms as the wound heals, and a crust or scab may develop over it to protect the new tissue underneath. This is not an indication of infection but rather a sign that the wound is progressing through the healing stages.

Choice A reason: The CRIES pain scale is not suitable for a 10-year-old as this scale is designed for neonates, typically those who are 0 to 6 months old.

Choice B reason: A 3-year-old toddler would be better assessed with a pain scale that allows for their level of understanding and communication, such as the Faces Pain Scale-Revised.

Choice C reason: A 4-year-old preschooler can typically communicate their pain verbally or by using a faces pain scale, making the CRIES scale less appropriate.

Choice D reason: The CRIES pain scale is specifically designed for neonates and is appropriate for assessing pain in a 4-day-old infant who cannot verbally communicate their pain.