Nokea
A patient comes to the clinic where you are working as a nurse. He had surgery 2 months ago and is very concerned. He asks you to feel the scar on his side. You feel a hard ridge beneath the incision scar extending about 1 cm on either side of the scar. Which response is most appropriate?
- A. This is a normal part of scar healing and strengthening. It will eventually thin out and become less hard.'
- B. This might be a keloid forming, which is an overgrowth of scar tissue. It is not dangerous.'
- C. This is very unusual at this stage of healing. The doctor will need to look at your scar.'
- D. Don't worry. Different people heal at different rates. You must just be a slow healer.'
Correct Answer: A
Rationale: A hard ridge under a scar is normal during the maturation phase of healing and typically softens over time.
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While assessing the skin of a patient on bedrest, you notice a pale area over the left hip with a small blister in the center. What action will you take?
- A. Massage the area vigorously with lotion to promote circulation.
- B. Notify the health-care provider that a pressure injury has developed.
- C. Document your findings and assess again in 2 hours.
- D. Order a special gel-filled mattress for the patient.
Correct Answer: B
Rationale: A pale area with a blister suggests a developing pressure injury, requiring immediate notification of the provider for intervention.
During the inflammatory process, which of the following physiological responses occur?
- A. Capillaries dilate, causing erythema and increased warmth at the site of injury.
- B. Leukocytes are shunted away from the site to fight infection.
- C. Leukocytes move into the interstitial space and attack microorganisms.
- D. Red blood cells deliver more oxygen and nutrients to promote healing.
- E. Fluid in the interstitial spaces prevents redness and pain.
- F. Edema causes pressure on nerve endings, resulting in discomfort and pain.
Correct Answer: A,C,D,F
Rationale: During inflammation, capillaries dilate (erythema and warmth), leukocytes migrate to fight infection, red blood cells supply oxygen/nutrients, and edema causes pain. Leukocytes are not shunted away, and fluid does not prevent redness/pain.
You are calling a health-care provider to report a possible wound infection. What information will you include in your report?
- A. Most recent vital signs
- B. Amount and type of wound drainage
- C. Observed signs of infection
- D. Type and frequency of bowel movements
- E. Patient's rating of his or her pain
- F. Amount of activity the patient has had in the past 24 hours
- G. Laboratory results
Correct Answer: A,B,C,E,G
Rationale: Vital signs, drainage, infection signs, pain, and lab results are critical for assessing and managing a potential wound infection.
In what order do wounds heal?
- A. Reconstruction phase, maturation phase, inflammatory phase
- B. Inflammatory phase, reconstruction phase, maturation phase
- C. Prodromal phase, symptoms phase, inflammatory phase, reconstruction phase
- D. Symptoms phase, maturation phase, inflammatory phase, reconstruction phase
Correct Answer: B
Rationale: Wounds heal in three phases: inflammatory (immediate response), reconstruction (tissue repair), and maturation (scar formation).
A patient with an open leg wound has the following laboratory results on his chart: WBC 15,350 mm^3 with an elevated percentage of neutrophils. What does this tell you about the patient's wound?
- A. He most likely no longer has any wound infection.
- B. He most likely has an acute wound infection.
- C. He most likely has a chronic wound infection.
- D. He most likely has a widespread bacterial infection.
Correct Answer: B
Rationale: Elevated WBC and neutrophils indicate an active immune response, typically seen in acute infections, suggesting the wound is acutely infected.