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1. 1The nurse is caring for a patient in the burn unit. Which type of wound
healing will the nurse consider when planning care for this patient?
a. Partial-thickness repair
b. Secondary intention
c. Tertiary intention
d. Primary intention
ANS: B
A wound involving loss of tissue such as a burn or a pressure ulcer or laceration
heals by secondary intention. The wound is left open until it becomes filled with
scar tissue. It takes longer for a wound to heal by secondary intention; thus the
chance of infection is greater. A clean surgical incision is an example of a wound
with little loss of tissue that heals by primary intention. The skin edges are
approximated or closed, and the risk for infection is low. Partial-thickness repair is
done on partial-thickness wounds that are shallow, involving loss of the epidermis
and maybe partial loss of the dermis. These wounds heal by regeneration because
the epidermis regenerates. Tertiary intention is seen when a wound is left open for
several days, and then the wound edges are approximated. Wound closure is
delayed until the risk of infection is resolved.
2. A nurse is assessing a patient’s wound. Which nursing observation will
indicate the wound healed by secondary intention?
a. Minimal loss of tissue function
b. Permanent dark redness at site
c. Minimal scar tissue
d. Scarring that may be severe
ANS: D
A wound healing by secondary intention takes longer than one healing by primary
intention. The wound is left open until it becomes filled with scar tissue. If the
scarring is severe, permanent loss of function often occurs. Wounds that heal by
primary intention heal quickly with minimal scarring. Scar tissue contains few
pigmented cells and has a lighter color than normal skin.
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