When assessing a wound in the remodeling phase of healing, the nurse would expect to find:
A) scar tissue formation.
B) acute inflammation.
C) a fibrin clot.
D) granulation tissue.
A) scar tissue formation.
Explanation: A) Remodeling is the final phase of wound healing. The goal of this phase is to restore the structural and functional integrity of the skin. However, the dermal matrix is not regenerated as is the epidermis; it is mended. Slowly, the granulation tissue laid down in the provisional matrix is replaced with a more stable collagen-based matrix. Although collagen deposition into the matrix began in the proliferative phase, it continues in the remodeling phase. The outcome of this dermal repair process is scar or fibrotic tissue, which brings the edges of the wound together.
B) The first phase of wound healing is acute inflammation. The goal of the inflammatory phase is to minimize tissue damage, prevent additional tissue injury, and prepare the wound for healing and regeneration.
C) Hemostasis, the first step in the inflammatory phase, controls hemorrhage and maintains vascular integrity. Two physiologic processes are involved: formation of a platelet plug and generation of a fibrin-based clot.
D) Granulation tissue forms during the proliferative phase. Granulation tissue is a mass of new connective tissue that forms on the surface of a healing wound. Granulation tissue serves as a foundation for the collagen-based matrix that will eventually replace the fibrin-based provisional matrix.
You might also like to view...
Students are observing a staff nurse who is empathic with the child undergoing chemotherapy. The students observe the nurse interplaying the internalized feelings of the child and the child's experiences or fantasies
The students recognize that the nurse, while fully absorbed in the identity of the child, still identifies himself as a separate personality. The student who correctly understands empathy recognizes the phase of empathy as: 1. Detachment. 2. Identification. 3. Reverberation. 4. Incorporation.
Knowing that there is a high rate of smoking in the local community, a nurse decides to lead a community health promotion group and seeks the hospital's backing. The nurse decides to organize the curriculum around the Lazarus Model of Stress
How does this model motivate smoking cessation? 1. By helping participants understand the nature of stress as a conflict 2. By helping participants understand stressors in their own lives 3. By encouraging the exploration of the pros and cons of smoking 4. By understanding the negative effects of stress on the body
What is the best indicator that the client is experiencing menopause?
1. No menses for eight consecutive months 2. Hot flashes and night sweats 3. High serum FSH with low serum estrogen 4. Diagnosed with osteoporosis four months ago
Which can occur with older adults who see multiple doctors and are prescribed multiple drugs?
A. drug toxicity B. cumulative effect C. drug tolerance D. drug interactions