The nurse is talking with a couple at a community health fair who ask how cancerous tumors occur. Which pathophysiological process supports the nurse's reponse about cancer cells developement?

Potential Conditions

Wound healing by secondary intention (Correct): This occurs when the wound is left open to heal from the inside out due to extensive tissue loss, high infection risk, or inability to approximate wound edges. The client’s wound is large, packed with gauze, and not sutured, indicating it is healing by secondary intention.

Wound healing by primary intention (Incorrect): Primary intention healing occurs when wound edges are surgically approximated with sutures or staples, allowing faster healing with minimal scarring. Since the client’s wound is open and packed, this is not the correct choice.

Actions to Take

Use sterile procedure to change dressing (Correct): Using sterile technique reduces the risk of infection and promotes wound healing, which is crucial for open wounds healing by secondary intention.

Encourage the client to consume a balanced diet (Correct): Proper nutrition, especially with protein, vitamin C, and zinc, enhances wound healing by supporting tissue regeneration and immune function.

Culture the wound (Incorrect): A wound culture is only necessary if there are signs of infection, such as increased drainage, foul odor, or worsening erythema. Since there is no mention of infection in the scenario, culturing the wound is not an immediate action.

Parameters to Monitor

Drainage on the dressing (Correct): Monitoring drainage helps assess healing progress and detect infection. An increase in purulent, foul-smelling, or discolored drainage may indicate complications.

The formation of granulation tissue (Correct): Granulation tissue, which is pink and bumpy, indicates healthy wound healing. Lack of granulation tissue suggests delayed healing.

Blood pressure (Incorrect): While blood pressure monitoring is important for overall health, it does not directly indicate wound healing progress.

Intake and output (Incorrect): Although hydration is important for healing, tracking intake and output is more relevant for clients at risk of fluid imbalances rather than wound healing assessment.

A. Immediate allergic reaction mediated by sensitized mast cells. This describes a Type I hypersensitivity reaction, which is an immediate allergic reaction. It involves IgE antibodies and mast cell degranulation, leading to symptoms such as hives, anaphylaxis, and respiratory distress. Latex allergies can involve Type I reactions, but delayed hypersensitivity is a Type IV reaction.
B. Antigen-antibody complexes deposit in tissues activating inflammation. This describes a Type III hypersensitivity reaction, which involves immune complex deposition leading to inflammation, as seen in lupus or serum sickness. Latex allergies do not involve immune complex deposition.
C. T-cells sensitization initiates the macrophage release of cytokines causing a delayed reaction. This describes a Type IV hypersensitivity reaction, which is a delayed-type hypersensitivity (DTH) mediated by T-cells rather than antibodies. In latex-induced delayed hypersensitivity, T-cells recognize latex proteins and release cytokines, leading to localized skin inflammation, rash, and itching, typically 24–48 hours after exposure.
D. Antibodies are formed against antigens on cell surfaces. This describes a Type II hypersensitivity reaction, which involves antibody-mediated destruction of cells, as seen in hemolytic anemia or blood transfusion reactions. Latex allergies do not involve direct antibody attack on cells.