A nurse is assessing a client who has a pressure ulcer on the sacrum. Which finding indicates a possible infection of the wound?

Correct Answer: C

Rationale: Increased pain and tenderness is the correct answer, indicating a possible infection in the pressure ulcer. Infection triggers an inflammatory response, heightening nerve sensitivity and causing more pain and tenderness, a shift from baseline that warrants a culture and provider input. Serous drainage is normal clear and watery unless it turns cloudy or purulent, which isn't specified here. Reddened periwound skin reflects healing-related blood flow, not infection, unless spreading or hot. Granulation tissue signifies healthy repair, not infection, unless it's pale or deteriorating. Pain and tenderness stand out as infection markers, as bacteria amplify inflammation, distinguishing this finding in a wound assessment and signaling a need for further investigation.

Correct Answer: D

Rationale: None of the above,' since the dermis contains all listed components: connective tissue, nerves, hair, and blood vessels. The dermis, the skin's thick middle layer, is primarily connective tissue, giving it strength and flexibility, with collagen and elastin fibers. Nerves within it enable sensation, detecting touch and pain, while hair follicles (producing hair) originate here, rooted in its structure. Blood vessels supply oxygen and nutrients, supporting its vitality. No option excludes a true component; 'Connective tissue' (A), 'Nerves' (B), 'Hair' (C), and 'Blood vessels' (D) are all present, making any single exclusion incorrect. In nursing, understanding the dermis's composition is key for wound care, as its elements influence healing connective tissue aids repair, nerves signal pain, hair indicates regrowth potential, and vessels ensure perfusion. Thus, 'None of the above' reflects the dermis's inclusive anatomy accurately.

Correct Answer: C

Rationale: Secondary intention,' as it describes large or open wounds, like burns or major trauma, left to heal naturally without edge approximation. These wounds, with significant tissue loss, fill in via granulation tissue and epithelialization from the base up, a slower process prone to scarring but suited for extensive damage. 'Primary intention' requires closed edges, impossible with large gaps. 'Delayed primary intention' involves eventual closure after initial openness, not leaving it alone entirely. 'Tertiary intention' also includes later surgical closure, not just natural healing. In nursing, secondary intention is key for managing burns dressings support granulation, not suturing. The question's focus on 'left alone' and large wounds aligns with C, distinguishing it from closure-based methods.

Correct Answer: A

Rationale: Primary intention,' as it describes Lois Griffin's heart transplant incision made deliberately, closed immediately with sutures post-surgery, promoting rapid healing with minimal scarring. Primary intention applies to clean, intentional wounds with edges approximated right after the procedure, typical in controlled surgical settings. 'Delayed primary intention' involves leaving the wound open briefly before closure, not immediate suturing as here. 'Secondary intention' is for wounds left open to heal naturally, unsuitable for a precise incision. 'Tertiary intention' combines initial openness with later closure, irrelevant to instant suturing. In nursing, primary intention is standard for surgeries like transplants, ensuring quick recovery and infection control. The question's focus on immediate closure rules out alternatives, making A the precise fit per wound healing classifications and surgical care protocols.