A patient has a surgical scar that extends beyond the original incision site. The area is raised and smooth, and the patient reports that it occasionally itches but is not tender. How would the nurse document this lesion?
1. Cicatrix
2. Hypertrophic scar
3. Fissure
4. Keloid
4
Rationale 1: A cicatrix is a scar. It does not manifest the additional findings described.
Rationale 2: A hypertrophic scar does not extend beyond the initial wound.
Rationale 3: A fissure is a linear crack or break from the epidermis to the dermis.
Rationale 4: A keloid results from the overproduction of scar tissue. It extends laterally beyond the initial wound and is usually raised and smooth. Keloids may or may not be tender and may itch.
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