What stage is a wound if the epidermis is closed and has unblanchable redness?

Stage 1

Stage 2

Stage 3

stage 4

Answer and Explanation

The Correct Answer is A

Choice A rationale

A wound at Stage 1 is characterized by intact skin with non-blanchable redness of a localized area, usually over a bony prominence. The skin remains unbroken with persistent redness that does not turn white when pressed. This stage indicates that the epidermis is closed.

Choice B rationale

Stage 2 involves partial-thickness loss of skin with exposed dermis. The wound bed is viable, pink or red, moist, and may also present as an intact or ruptured serum-filled blister. This stage is not applicable if the epidermis is closed.

Choice C rationale

Stage 3 is defined by full-thickness skin loss, where fatty tissue is visible in the wound, and granulation tissue and epibole (rolled wound edges) are often present. This stage indicates a more severe wound than what is described in the scenario.

Choice D rationale

Stage 4 represents full-thickness skin and tissue loss with exposed or directly palpable fascia, muscle, tendon, ligament, cartilage, or bone. The condition described does not match the severity of a Stage 4 wound.

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Correct Answer is C

Explanation

Choice A rationale
Applying oxygen at 2 L/min via nasal cannula is not typically indicated in the initial stage of wound healing. Oxygen therapy is used for clients with respiratory distress or hypoxia, not as a standard wound care procedure.

Choice B rationale
Mechanical debridement is a method used to remove dead tissue from wounds, but it is not usually part of the initial wound care plan. Debridement is considered when there is necrotic tissue present that may impede healing.

Choice C rationale
Leaving non-bleeding wounds open to air can be beneficial during the initial stage of wound healing. Exposure to air can help to dry out the wound and prevent maceration of the surrounding skin. It also allows for the observation of the wound and easy access for dressing changes if needed.

Choice D rationale
Administering a corticosteroid medication is not a standard part of initial wound care. Corticosteroids can actually delay wound healing and are generally avoided unless there is a specific indication, such as an inflammatory skin condition.

A. Adequate fibroblast function B. Intrinsic factor C. Synthesis of collagen D. Hemoglobin E. Adequate phagocytosis

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

Explanation

Choice A rationale
Adequate fibroblast function is crucial for wound healing as fibroblasts play a key role in the formation of new connective tissue and collagen, which are essential for the repair process.

Choice B rationale
Intrinsic factor is not directly related to wound healing; it is a glycoprotein produced by the stomach lining that is necessary for the absorption of vitamin B12.

Choice C rationale
The synthesis of collagen is vital for wound healing because collagen is the main structural protein in the skin and other connective tissues, providing strength and support to the wound site.

Choice D rationale
While hemoglobin is essential for transporting oxygen in the blood, it is not a factor in the local wound healing process.

Choice E rationale
Adequate phagocytosis is important in wound healing as it involves the ingestion and removal of pathogens and debris by phagocytes, which is a critical step in preventing infection and allowing the healing process to proceed.

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What stage is a wound if the epidermis is closed and has unblanchable redness?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has multiple wounds. During the initial stage of wound healing, which of the following should the nurse include in the plan of care?

Correct Answer is C

Explanation

A nurse is concerned about an HIV immunocompromised patient’s ability to heal due to a lack of certain factors. Which of the following are necessary for proper wound healing? (Select all that apply.)

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

Explanation

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