The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?

Primary Intention

Partial-thickness repair

Secondary Intention

Tertiary intention

Answer and Explanation

The Correct Answer is A

A. Primary Intention: Primary intention healing occurs when surgical incisions are closed with sutures, staples, or adhesive strips. Since laparoscopic procedures involve small incisions that are closed immediately, this type of healing applies.

B. Partial-thickness repair: Partial-thickness repair refers to wounds that involve only the epidermis and part of the dermis (e.g., abrasions, minor burns). Surgical incisions are full-thickness wounds, so this is not applicable.

C. Secondary Intention: Secondary intention healing occurs when wounds heal from the inside out, typically seen in pressure ulcers, large open wounds, or infected wounds. Surgical wounds that are sutured do not heal by secondary intention.

D. Tertiary Intention: Tertiary intention healing occurs when a wound is left open initially and later closed due to infection risk or delayed healing. Laparoscopic appendectomy wounds are closed immediately, making this choice incorrect.

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Correct Answer is D

Explanation

A. "I will treat all the family members to be on the safe side." Treatment is only recommended for individuals who have active lice or close, prolonged contact with the infected child. Treating everyone unnecessarily may lead to overuse of medications.

B. "My child must be free from nits before returning to school." The CDC and AAP do not recommend "no-nit" policies, as nits alone do not indicate active infestation. Children can return to school after appropriate treatment begins.

C. "Toys that can't be dry cleaned or washed must be thrown out." Non-washable items should be sealed in a plastic bag for 2 weeks to kill lice, rather than being thrown away.

D. "All recently used clothing, bedding, and towels must be washed in hot water." Lice and nits can survive on fabric surfaces, so washing clothing, bedding, and towels in hot water (≥130°F/54°C) and drying on high heat is recommended to eliminate them.

A. Report by patient that something has given way B. Drainage that is odorous and purulent C. Protrusion of visceral organs through a wound opening D. Chronic drainage of fluid through the incision site

Correct Answer is A

Explanation

A. Report by patient that something has given way: A patient reporting a "giving way" sensation is a classic early sign of dehiscence, indicating that the wound edges are separating.

B. Drainage that is odorous and purulent: Purulent (pus-like) and foul-smelling drainage suggests infection, not necessarily dehiscence. Infection can contribute to dehiscence, but it is not the defining feature.

C. Protrusion of visceral organs through a wound opening: Evisceration occurs when internal organs protrude through the incision. Dehiscence is partial or complete separation of the wound edges without organ protrusion.

D. Chronic drainage of fluid through the incision site: Persistent drainage suggests a fistula (abnormal connection between tissues), infection, or poor wound healing, rather than wound dehiscence.

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The nurse is caring for a patient who has experienced a laparoscopic appendectomy. For which type of healing will the nurse focus the care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is D

Explanation

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Correct Answer is A

Explanation

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