Which complication is a nurse most likely to suspect if a patient develops erythema and warmth around a wound after a sterile dressing change?

Choice A reason: Identifying problem areas is a primary task of the working phase, where the nurse and client collaborate to analyze the factors contributing to the eating disorder and develop strategies for behavioral change. While initial assessments occur in the orientation phase, the deep work of problem identification happens once rapport is established.

Choice B reason: Self-reflection is an ongoing responsibility of the nurse throughout every stage of the relationship to ensure that professional boundaries are maintained and that personal biases do not interfere with patient care. It is not an activity performed specifically as a task with the client during the orientation phase.

Choice C reason: The orientation phase is focused on establishing the parameters of the professional relationship. This includes introducing the nurse and client, establishing trust, setting goals, defining roles, and explicitly discussing the timeline, including when the relationship will terminate. This structure provides the patient with necessary security and clear expectations.

Choice D reason: Reinforcing teaching is an ongoing process that is most effective once the client is stable and a therapeutic alliance has been formed. While some education may be introduced early, intensive teaching is a component of the working phase, after the client has developed enough trust to process the information and apply it to their life.

Choice A reason: A wound contaminated at the time of injury would typically require secondary intention healing, as the presence of debris or pathogens necessitates leaving the wound open to prevent infection. First intention healing, or primary union, requires a clean incision that is not contaminated at the time of the procedure.

Choice B reason: Granulation tissue formation is a hallmark characteristic of secondary intention healing, where a large tissue defect must be filled from the base upward. In first intention healing, there is minimal tissue loss, and the wound edges are approximated, meaning there is little to no space for significant granulation to occur.

Choice C reason: First intention healing occurs in wounds with straight, clean edges, such as surgical incisions, where the wound margins are approximated using sutures, staples, or adhesive strips. By closing the wound immediately, the body can facilitate faster epithelialization and minimize the amount of scar tissue required to bridge the wound gap.

Choice D reason: Healing by first intention is the fastest method of wound repair, as the closed edges minimize the surface area that requires epithelial regeneration. Conversely, secondary intention is characterized by prolonged healing times due to the need for granulation and contraction of the wound bed over an extended period.