Which primary lesions are associated with acne caused by sebum blockage in hair follicles?

Choice A rationale

The largest area of the body without hair is not selected as it is not necessary for the graft to be hairless. The primary concern is matching the color and texture, not the absence of hair.

Choice B rationale

Any area that is not normally visible is not ideal as visibility is not the primary concern. The donor site needs to match the surgical site in color and texture to ensure a natural appearance.

Choice C rationale

An area matching the color and texture of the skin at the surgical site is selected to ensure the graft blends well with the surrounding skin and appears natural once healed.

Choice D rationale

An area matching the sensory capability of the skin at the surgical site is not typically a concern in graft selection. The focus is on the appearance and integration of the graft.

Choice A rationale

Palpating the client's skin for moisture, temperature, and texture is essential in wound management. This allows the nurse to assess for signs of infection or inflammation, which can affect the wound healing process. Moisture can indicate excessive drainage or sweating that might macerate the skin, while changes in temperature and texture can signify infection or poor blood flow.

Choice B rationale

While asking the client whether the wound bed or surrounding skin itches may provide some information about the client's comfort, it is not a primary intervention for wound management. Itching can be a sign of healing or irritation, but it does not provide direct information on the wound's condition.

Choice C rationale

Measuring and assessing the wound bed, size, edges, and margins are critical steps in wound management. This helps to determine the progression of healing, the presence of necrotic tissue, and any changes in the wound over time. Accurate measurement and documentation are essential for developing an appropriate care plan.

Choice D rationale

Evaluating the client's level of pain using a numeric value pain scale is important in wound management. Pain can indicate underlying issues such as infection, poor perfusion, or neuropathy. Assessing pain helps guide interventions to provide comfort and address any complications that may arise.

Choice E rationale

Reviewing the client's prothrombin time test and international normalized ratio is not a standard intervention for wound management. These tests are more relevant to assessing the client's coagulation status, which may be important for surgical or anticoagulant therapy but not directly for wound care.