The nurse cares for a client who arrives at the urgent care center after an injury. The nurse notes, upon assessment, the separation of skin and tissue, in which the edges are torn and irregular. The nurse should document this as what type of wound?
Avulsion
Incision
Laceration
Ulceration
The Correct Answer is C
A. Avulsion: Avulsion involves forcible tearing away of tissue, often with a flap or loss of tissue; it may be extensive but implies more tissue loss rather than just jagged edges.
B. Incision: An incision is a clean, straight surgical cut with tidy edges, not torn or irregular.
C. Laceration: A laceration is characterized by torn, irregular wound edges and separation of tissue, matching this description.
D. Ulceration: An ulcer is a crater-like lesion from tissue breakdown (pressure, ischemia, necrosis), not primarily described as torn, irregular edges from trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "I will review your chart and be right back.": This avoids the patient's expressed anxiety and delays addressing concerns; it doesn’t provide reassurance or information.
B. "This is nothing to worry about. I won't hurt you.": Minimizes the patient's feelings and can erode trust; reassurance should be realistic and informative.
C. "I will tell you everything that I am doing.": Explaining each step reduces uncertainty and empowers the patient, which is the most therapeutic choice for anxious clients.
D. "I have to do this, so just relax. It won't take long.": Dismissive and directive; does not acknowledge the patient's anxiety or provide needed information.
Correct Answer is B
Explanation
A. Prevention of wound infection: Pneumatic compression devices do not actively prevent surgical wound infection; infection prevention relies on aseptic technique, antibiotics as indicated, and wound care.
B. Promote circulation of venous blood: These devices intermittently compress the limbs to enhance venous return, reduce venous stasis, and lower the risk of deep vein thrombosis (DVT).
C. Improve mobility: While used when mobility is limited, the devices themselves do not restore or improve the patient’s ability to ambulate.
D. Encourage lung expansion: Lung expansion is promoted by deep-breathing exercises, incentive spirometry, and positioning; pneumatic compression devices target limb circulation rather than pulmonary mechanics.
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