The nurse is caring for a young client with a large wound on the arm from necrotizing fasciitis. The nurse knows this client has psychologically adjusted to this wound when the client states:
1. "I am able to look at my wound during dressing changes.".
2. "I told my family it would heal without a scar.".
3. "I will wear long sleeves for the rest of my life.".
4. "I told my mother that she should not look at the wound.".
"I am able to look at my wound during dressing changes.".
Rationale: Looking at the wound during dressing changes is a sign that the client is beginning to accept the fact that the wound is there. Telling the family it will heal without a scar is denial on the part of the client. Full-thickness injures always leave scars. Wearing long sleeves means that the client does not want anyone to see the scar, which is an indication that the client is bothered by the wound. Telling her mother that she should not look at the wound is not an indication that the client has accepted the wound.
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