The nurse is providing health teaching to a client with a wound. Which of the following should be included in the teaching?
Adequate nutrition delays wound healing and increases risk of infection.
Chronic wounds heal better in a dry, open environment so leave them open to air.
Fat tissue heals more rapidly because there is less vascularization.
Long term steroid use diminishes the inflammatory response and delays wound healing.
The Correct Answer is D
Rationale:
A. Adequate nutrition actually promotes wound healing. Poor nutrition, especially a lack of protein and vitamins, delays healing and increases the risk of infection.
B. Chronic wounds heal better in a moist environment rather than a dry one. Moist wound healing promotes cell migration and prevents scab formation, improving healing.
C. Fat tissue does not heal more rapidly. In fact, it heals more slowly due to decreased vascularization, which impairs oxygen delivery and nutrient supply to the tissue.
D. Long-term steroid use diminishes the body’s inflammatory response, reducing the body's ability to initiate the healing process. This delay in inflammation can lead to slower wound healing and a higher risk of infection.
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View Related questions
Correct Answer is B
Explanation
Rationale:
A. Being male is not a significant risk factor for developing pressure ulcers. Pressure ulcers are more related to factors like immobility, nutritional status, and circulation.
B. Immobility is a major risk factor for pressure ulcer development. Clients who are immobile or confined to bed, especially for prolonged periods, are at higher risk due to continuous pressure on certain body areas, leading to skin breakdown.
C. Adequate hydration helps maintain skin integrity and is not a risk factor for pressure ulcers. Dehydration, rather than adequate hydration, can contribute to skin breakdown.
D. Anemia can impact tissue oxygenation, but immobility is a more direct risk factor for pressure ulcer development. Although anemia can slow healing, immobility leads to constant pressure on the skin, causing tissue breakdown and ulceration.
Correct Answer is D
Explanation
Rationale:
A. A Stage 1 pressure ulcer is characterized by intact skin with non-blanchable redness; it does not involve any tissue loss or visible subcutaneous tissue, which is present in this case.
B. A Stage 4 pressure ulcer involves full-thickness tissue loss with exposed bone, muscle, or tendon; while this wound has visible subcutaneous tissue, it does not exhibit the depth or extent associated with Stage 4.
C. A Stage 2 pressure ulcer is defined by partial-thickness skin loss involving the epidermis and possibly the dermis, presenting as a blister or abrasion. This wound shows more depth and visible subcutaneous tissue, which indicates it is deeper than a Stage 2.
D. A Stage 3 pressure ulcer involves full-thickness skin loss, with visible fat and possible slough. The presence of minimal slough and visible subcutaneous tissue in this wound aligns with the characteristics of a Stage 3 ulcer.