What type of tissue in the wound bed indicates healthy healing?
Presence of slough
Presence of granulation tissue
Presence of necrotic tissue
Presence of eschar
The Correct Answer is B
A. Presence of slough: Slough is yellow, white, or stringy tissue in the wound bed that represents dead or devitalized tissue. Its presence indicates impaired healing and requires debridement for the wound to progress.
B. Presence of granulation tissue: Granulation tissue is pink or red, moist, and composed of new connective tissue and capillaries. Its presence signals healthy wound healing, as it fills the wound bed and provides a foundation for epithelialization.
C. Presence of necrotic tissue: Necrotic tissue is black, brown, or gray and consists of dead cells. It impedes healing, increases infection risk, and must be removed to allow the wound to progress toward closure.
D. Presence of eschar: Eschar is a dry, leathery scab or crust that forms over a wound, usually composed of dead tissue. Like necrotic tissue, eschar must be debrided for healing to continue and does not indicate healthy tissue.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. "A fever may be an indicator that the inflammation has become systemic.": Fever is a body’s non-modifiable response to infection and inflammation. While important for identifying systemic involvement, the client cannot directly modify this defense mechanism.
B. "A balanced diet helps your immune system function properly.": Nutrition is a modifiable factor that supports the immune system by providing essential vitamins, minerals, and proteins needed for immune cell production and function. Clients can take direct action through diet to enhance infection prevention.
C. "Your skin acts as a barrier to microorganisms and helps prevent injury.": Skin integrity is a natural, non-modifiable defense mechanism. While clients can care for their skin, its barrier function is inherently physiological and not directly alterable.
D. "Tears reduce particles entering the eye, reducing the number of organisms.": Tear production is a natural defense mechanism. Although hygiene can support eye health, the production and function of tears are not directly modifiable by the client.
Correct Answer is B
Explanation
A. “I will use the cane to support all of my weight when walking.": A cane is meant to provide partial support and improve balance, not bear the client’s full weight. Relying entirely on the cane can cause instability and increase the risk of falls.
B. "I will make sure my elbow is bent slightly when I hold the cane.": Proper cane use requires a slight elbow flexion of about 20–30 degrees. This position ensures optimal support, reduces strain on the shoulder and wrist, and promotes safe ambulation.
C. "I will move the strong leg up the stairs first, then the cane, and then the weak leg.": When using a cane, it should move simultaneously with the weaker leg while ascending or descending stairs to provide support. Moving the strong leg first without coordinating the cane can compromise safety.
D. “I will hold the cane on the weak side of my body to support it.": The cane should be held on the strong side to provide counterbalance and allow the weaker leg to bear weight safely. Holding it on the weak side decreases stability and increases fall risk.
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