The nurse notes that the 43-year-old male client has an abrasion ...

[Beheh]

The nurse notes that the 43-year-old male client has an abrasion on his upper right thigh that he received 2 days ago when he was involved in a bicycle accident. The abrasion is red, swollen, warm, and throbbing.
 
  The nurse knows that the wound shows signs of being:
  1. Infected
  2. In the inflammatory phase of healing
  3. In the proliferative phase of healing
  4. In the remodeling phase of healing

Question 2

The nursing student is bathing a 73-year-old Native American female client. The student reports to the nurse that the client has what looks like cyanosis on her sacrum.
 
  The nurse goes with the student to assess the client but suspects that the cyanosis that the student sees is most likely:
  1. Caused from the client laying on her back most of the morning
  2. Caused by the bright sunlight in the room
  3. Normal hyperpigmentation of mongolian spots
  4. Blue dye that has bled off the cheap new gowns that the hospital has purchased

[mohan]

Answer to Question 1

ANS: 2
The inflammation stage is the body's reaction to wounding and begins within minutes of injury and lasts approximately 3 days. The inflammatory response is beneficial, and there is no value in attempting to cool the area or reduce the swelling unless the swelling occurs within a closed compartment. Some contaminated or traumatic wounds show signs of infection early, within 2 to 3 days. The client has a fever, tenderness and pain at the wound site, and an elevated white blood cell count. The edges of the wound appear inflamed. If drainage is present, it is odorous and purulent, which causes a yellow, green, or brown color, depending on the causative organ-ism. With the appearance of new blood vessels as reconstruction progresses, the proliferative phase begins and lasts from 3 to 24 days. The main activities during this phase are the filling of the wound with granulation tissue, contraction of the wound, and the resurfacing of the wound by epithelialization. Maturation, the final stage of healing, sometimes takes place for more than a year, depending on the depth and extent of the wound..

Answer to Question 2

ANS: 3
The nurse should not confuse the normal hyperpigmentation of mongolian spots that are seen on the sacrum of African, Native American, and Asian clients as cyanosis. Observe the client's skin in nonglare daylight. The Gaskin's Nursing Assessment of Skin Color (GNASC) is a useful tool for assessment for identifying changes in skin color that increase the client's risk for pressure ul-cers.

[Beheh]

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[mohan]

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