When the patient complains of worsening due to increased swelling at the wound site on his leg, the nurse explains that the swelling indicates:
He has lain in one position for such a long time that swelling has occurred.
An infection is in progress at the wound site.
There is probably a deeper injury than what appears on the surface.
Vessels have dilated and allowed plasma to leak into the wound site.
The Correct Answer is D
Choice A rationale
Prolonged immobility can indeed cause swelling due to fluid accumulation; however, it typically does not lead to sudden worsening or significant swelling at a specific wound site. It is more associated with generalized edema, particularly in dependent areas of the body.
Choice B rationale
While infections can cause swelling, they are also accompanied by other signs such as redness, warmth, pain, and possibly fever. Swelling alone, without these other symptoms, is less indicative of an infection.
Choice C rationale
A deeper injury might cause swelling, but this would have been identified during the initial assessment. Swelling that occurs later in the healing process is less likely to be from a deeper, previously unnoticed injury.
Choice D rationale
Swelling at a wound site is often due to inflammation, where blood vessels dilate and become more permeable, allowing plasma to leak into the tissue. This is a normal part of the healing process as the body brings in necessary cells and substances to promote recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
A contusion, commonly known as a bruise, is characterized by skin discoloration due to trauma that causes bleeding under the skin. It does not result in a raised scar, which is why it is not the correct term to describe the patient's condition.
Choice B rationale
A keloid is an overgrowth of scar tissue that forms at the site of a healed skin injury. Keloids are more common in people with darker skin tones, such as African Americans, and are characterized by a raised, firm, and sometimes itchy or painful scar that extends beyond the original wound boundaries. This description matches the nurse's assessment of the patient's scar.
Choice C rationale
A laceration refers to a deep cut or tear in the skin or flesh. Because the nurse is assessing a scar, not a fresh wound, laceration is not the appropriate term for documentation.
Choice D rationale
A hematoma is a localized collection of blood outside the blood vessels, usually in liquid form within the tissue. This term would not be used to describe a raised scar, making it an incorrect choice for documentation.
Correct Answer is C
Explanation
Choice A rationale
Leaving the old dressing in place and simply covering it with new wet dressings would not address the issue of the dressing being adhered to the wound bed, which could lead to further tissue damage when it is eventually removed.
Choice B rationale
Povidone-iodine is an antiseptic and not typically used to moisten dressings that are stuck to a wound bed, as it may irritate the wound and delay healing.
Choice C rationale
Adding normal saline is the gentlest method to loosen a dressing that is stuck to a wound bed. It helps to rehydrate the dressing and the wound, making it easier to remove without causing additional trauma to the healing tissue.
Choice D rationale
Pulling off the dressing using slow, steady pressure could cause damage to the new tissue forming in the wound bed and should be avoided unless all other methods have failed.
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