Author Question: Following a head injury, the client has thin drainage coming from the left ear. The nurse describes ... (Read 69 times)

nmorano1 · **on:** Jul 23, 2018

Following a head injury, the client has thin drainage coming from the left ear. The nurse describes this drainage as:

1. Serous
2. Purulent
3. Cerebrospinal fluid
4. Serosanguineous

Question 2

A client has a healing abdominal wound. The wound has minimal exudate and collagen for-mation. The wound is identified by the nurse as being in which phase of healing?

1. Primary intention
2. Inflammatory phase
3. Proliferative phase
4. Secondary intention

stanleka1 · **Reply #1 on:** Jul 23, 2018

Answer to Question 1

ANS: 1
Serous drainage is clear, watery plasma. Purulent drainage is thick, yellow, green, tan, or brown. Drainage must be tested to determine if it is cerebrospinal fluid. The nurse should de-scribe the drainage by its appearance (i.e., serous). Serosanguineous drainage is pale, red, and watery, a mixture of clear and red fluid.

Answer to Question 2

ANS: 3
During the proliferative phase, the wound fills with granulation tissue (including collagen for-mation), the wound contracts, and the wound is resurfaced by epithelialization. Primary intention is not a phase of wound healing. Wounds that heal by primary intention have minimal tissue loss, such as a surgical wound. The edges are approximated and the risk for infection is low. During the inflammatory phase, platelets gather to stop bleeding, a fibrin matrix forms, and white blood cells reach the wound, clearing it of debris. Secondary intention is not a phase of wound healing. Wounds that heal by secondary intention have loss of tissue, such as a pressure ulcer. The wound is left open until it becomes filled by scar tissue.