A client is admitted to the hospital with a diabetic foot ulcer. The nurse notes that the wound has black, dry, and hard tissue covering most of the wound bed. How should the nurse document this finding?

Correct Answer: A

Rationale: Eschar is the correct documentation for black, dry, and hard tissue covering a diabetic foot ulcer's wound bed. Eschar is necrotic tissue that's firm and adherent, often stable (dry, intact) or unstable (moist, loose), and in diabetic wounds, it delays healing and risks infection, requiring accurate identification. Slough is softer, moist, and typically yellow or green, not matching the dry, hard description. Fibrin is a yellowish clotting protein, not black or extensive like eschar. Exudate is fluid, not tissue, and doesn't fit. Eschar's distinct characteristics color, texture, and dryness differentiate it, and proper documentation guides treatment, like debridement, critical for diabetic wound management to prevent complications like osteomyelitis.

Correct Answer: D

Rationale: Elimination,' as this function describes the skin's role in excreting water, electrolytes, and nitrogenous wastes through sweat. Sweat glands produce sweat, a mixture containing these substances, aiding in waste removal and electrolyte balance, albeit in small amounts compared to kidneys. 'Protection' refers to the skin's barrier against pathogens and injury, not excretion. 'Sensation' involves nerve endings detecting stimuli, unrelated to waste. 'Regulation' covers temperature control via sweating or vasoconstriction, but the question specifies excretion, not thermoregulation. Elimination uniquely fits, as it's a recognized skin function in physiology, crucial for nursing knowledge in fluid balance and patient assessment e.g., excessive sweating might signal electrolyte loss. This specificity distinguishes 'Elimination' as the precise answer, aligning with the skin's excretory role.

Correct Answer: B

Rationale: Delayed primary intention,' as it fits Mr. Griffin's case: a large wound left open initially to heal naturally (allowing granulation and infection control), then sutured later. This method delays primary closure until the wound bed is stable, common for contaminated or traumatic injuries. 'Primary intention' involves immediate suturing, not waiting days. 'Tertiary intention' implies prolonged openness with later closure after significant healing, often for deeper wounds, but the question suggests a shorter delay. 'B and C' is incorrect only one process applies here. In nursing, delayed primary intention balances infection risk and closure, critical for trauma care. The sequence of open healing then suturing pinpoints B as the accurate description.

Correct Answer: A

Rationale: Hemostasis,' as it's the phase where blood vessels constrict to stop bleeding via clotting, then dilate to enhance permeability, leaking plasma and blood components into the injury site. Hemostasis, the first wound healing stage, begins instantly post-injury vasoconstriction forms a clot, followed by vasodilation to initiate inflammation. 'Inflammatory phase' follows, focusing on immune response (e.g., neutrophil influx), not initial clotting. 'Proliferation phase' involves tissue rebuilding, not vessel dynamics described here. 'A and B' is incorrect constriction and dilation are hemostasis-specific, not inflammatory. In nursing, recognizing hemostasis aids early wound assessment e.g., excessive bleeding signals issues. The question's vessel behavior pinpoints A, distinguishing it from later phases.