The nurse documenting an acute open wound should include which characteristics? Select all that apply.

Wound size.

Wound bed.

Periwound skin.

Pattern of eruption.

Answer and Explanation

Correct Answer : A,B,C

Choice A rationale

Documenting wound size includes measuring the length, width, and depth of the wound to track the healing process and plan appropriate interventions.

Choice B rationale

The wound bed should be assessed for tissue type (granulation, slough, or eschar), color, and the presence of any exudate or infection.

Choice C rationale

The periwound skin is the area around the wound which should be assessed for color, temperature, swelling, and signs of maceration or excoriation.

Choice D rationale

Pattern of eruption is more relevant to dermatological conditions such as rashes or lesions, and not a primary focus for documenting acute open wounds.

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Correct Answer is B

Explanation

Choice A rationale

Hematoma formation is the initial stage of fracture healing, where a blood clot forms around the fracture site, creating a foundation for subsequent healing phases.

Choice B rationale

Remodeling is the final phase of bone healing, where compact bone replaces spongy bone, restoring the bone's structure and function.

Choice C rationale

Bony callus formation involves the development of new bone (callus) around the fracture site, which eventually transitions to compact bone during remodeling.

Choice D rationale

Fibrocartilaginous callus formation is an earlier stage of fracture healing, characterized by the formation of a soft callus made of collagen and cartilage that stabilizes the fracture.

A. Scales. B. Erosion. C. Crusts. D. Ulcers.

Correct Answer is ["A","B","C"]

Explanation

Choice A rationale

Scales represent the accumulation of dead skin cells that flake off, a common secondary lesion in eczema resulting from the chronic inflammation and rapid skin cell turnover.

Choice B rationale

Erosion occurs when the superficial layer of skin is lost, typically due to scratching or friction in eczema, exposing the underlying epidermis and sometimes leading to infection.

Choice C rationale

Crusts form when serum, blood, or purulent exudate dries on the skin surface, often seen in eczema as a result of weeping lesions and subsequent drying.

Choice D rationale

Ulcers are deeper lesions extending into the dermis or subcutaneous tissue and are not typically associated with eczema. Eczema usually affects the epidermis, causing secondary lesions like scales, erosion, and crusts rather than deep tissue ulcers.

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The nurse documenting an acute open wound should include which characteristics? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client's fracture is healing and compact bone is replacing spongy bone around the periphery of the fracture. This process characterizes what phase of the bone healing process?

Correct Answer is B

Explanation

Which secondary skin lesions are associated with eczema?

Correct Answer is ["A","B","C"]

Explanation

Which primary lesions are associated with acne caused by sebum blockage in hair follicles?

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The nurse assesses two new wounds located on a client's right and left buttocks. Which intervention for wound management would the nurse employ? Select all that apply.