The nursing student is listing the phases of full-thickness wound healing to the nursing mentor. Which of the following phases she lists indicate she needs further education? (Select all that ap-ply.)
a. Inflammatory phase
b. Hemostasis
c. Primary intention
d. Proliferation
e. Remodeling
f. Secondary intention
C, F
Wound healing occurs in four stages. (1) Hemostasis: Blood vessels constrict; clotting factors activate coagulation to stop bleeding. Clot formation seals disrupted vessels so blood loss is con-trolled and acts as a temporary bacterial barrier. Growth factors are released, which attract cells needed to begin tissue repair. (2) Inflammatory phase: Vasodilation occurs, allowing plasma and blood cells to leak into the wound, noted as edema, erythema, and exudate. Leukocytes (WBCs) arrive in the wound to begin cleanup. Macrophages appear and regulate the wound repair. (3) Proliferation/rebuilding phase: New capillaries are created, restoring the delivery of oxygen and nutrients to the wound bed. At the same time new granulation tissue is formed. Collagen is syn-thesized and begins to provide strength and structural integrity to a wound. Contraction reduces the size of the wound. Epithelial resurfacing (the construction of new epidermis) begins to cover the wound. (4) Maturation/remodeling phase: Collagen is remodeled to become stronger and provide tensile strength to the wound. Outer appearance in an uncomplicated wound will be that of a well-healed scar. Healing by primary intention occurs when the wound edges of a clean sur-gical incision remain close together. Wounds left open and allowed to heal by scar formation are classified as healing by secondary intention.
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Which of the following types of communication often is not a natural behavior for nurses?
1. Assertive communication 2. Aggressive communication 3. Caring communication 4. Subjective communication
An older male client with chronic gastritis asks the nurse, "Do you think I'll get gastric cancer?" The most accurate response by the nurse is
a. "As long as the chronic gastritis is diagnosed early, there is little risk of gastric cancer." b. "Chronic gastritis is not associated with the development of gastric cancer in men over 40." c. "Individual predictions are not possible, but chronic gastritis is associated with the development of gastric cancer." d. "Women with chronic gastritis are more likely to get gastric cancer than men who have chronic gastritis."
A client is being discharged with scheduled doses of morphine every 8 hours. The goals for discharge teaching have been met when the client says "I will
a. eat high fiber foods and drink lots of fluids to avoid constipation." b. monitor my blood pressure carefully, and report any elevations over ." c. take the morphine with food to avoid GI upset and possible stomach ulceration." d. notice a decrease in pain in about a week."
The home health nurse counsels a family in making safe driving "rules" for their 85-year-old father. Which rule would not be effective in promoting safety?
a. Limit driving to nearby areas with easy access. b. Plan ahead and know where you are going. c. Wear prescribed glasses and hearing aids. d. Drive below the speed limit to maintain control of the car.