Question 1

Which finding would the nurse expect when assessing a full thickness wound?

Accepted Answer

A full thickness wound involves the destruction of both the epidermis and the full thickness of the dermis.

Question 2

Which instruction should be included in the teaching plan for a patient with a chronic wound?

Accepted Answer

Smoking cessation is important for wound healing as smoking can impair blood flow and oxygen delivery to tissues, which are crucial for the healing process.

Question 3

When assessing a patient's skin, the nurse needs to keep in mind that:

Accepted Answer

Both light-skinned and dark-skinned people have the same number of melanocytes; the difference in skin color is due to the amount and type of melanin produced by these cells, not the number of melanocytes.

Question 4

What type of wound would the nurse expect to find in a patient who has a wound healing by primary intention?

Accepted Answer

Primary intention healing occurs in clean, well-approximated surgical wounds where the edges are brought together, typically with sutures or staples, allowing for minimal scarring.

Question 5

In formulating a plan of care for a patient with colon cancer who will be having a colon resection, which local factor should the nurse recognize as affecting wound healing?

Accepted Answer

Reduced blood flow and hypoxia are local factors that directly affect the wound healing process by limiting the supply of oxygen and nutrients necessary for tissue repair.

Question 6

The nurse in preadmission testing is taking a health history from a patient who will be having an elective hysterectomy. Which vitamin deficiency should be addressed before surgery to ensure proper blood clotting during surgery?

Accepted Answer

Vitamin K is essential for the synthesis of clotting factors, which are necessary for proper blood clotting during surgery.

Question 7

Which nutritional deficiencies should the plan of care address to improve oxygen delivery and wound healing in the patient with a pressure ulcer?

Accepted Answer

The answer of Which nutritional deficiencies should the plan of...

Question 8

Which response by a parent of a 24-week-old fetus undergoing intrauterine surgery indicates that the parent understands fetal wound healing?

Accepted Answer

Fetal wound healing is unique in that it occurs with little or no scarring, especially in the early gestational period, such as at 24 weeks.

Question 9

What characteristics would the nurse expect to assess in a patient with a keloid scar?

Accepted Answer

Keloid scars extend beyond the borders of the original injury and are often raised, pruritic, and can be edematous.

Question 10

The nurse is caring for four patients who have abdominal surgical wounds. Which patient in this surgical nurse's assignment does the nurse assess to be at greatest risk for wound dehiscence?

Accepted Answer

Patients with diabetes are at a higher risk for wound healing complications, including dehiscence, due to impaired blood flow and potential for infection.

Question 11

Which assessment findings would alert the nurse of an impending wound dehiscence on a patient with an abdominal incision on postoperative day 5?

Accepted Answer

Purulent drainage from the abdominal dressing indicates infection, which can weaken the incision site and increase the risk of wound dehiscence.

Question 12

When assessing a patient's skin, which of the following characteristics of skin should the nurse keep in mind?

Accepted Answer

The blood vessels in the dermis provide nourishment to the epidermis, which is avascular.

Question 13

When changing the dressing on a wound healing by secondary intention, what finding would the nurse expect to observe?

Accepted Answer

In secondary intention healing, the wound is left open to heal naturally, resulting in more exudate and granulation tissue as the body works to fill in the wound.

Question 14

The nurse is providing discharge instructions to a patient with multiple lacerations and puncture wounds following a motor vehicle accident. Which statement by the patient indicates an understanding of the instructions?

Accepted Answer

The answer of The nurse is providing discharge instructions to...

Question 15

When assessing a surgical wound healing by tertiary intention, the nurse expects granulation tissue to begin to appear during which time period?

Accepted Answer

Granulation tissue typically begins to form 3-5 days after surgery in wounds healing by tertiary intention, as the wound is initially left open to allow for drainage or infection control before being closed.

Question 16

Following change-of-shift report, the nurse on a surgical unit is reviewing the assignment. Which 70-year-old patient does the nurse assess as being at greatest risk for impeded wound healing?

Accepted Answer

Diabetes mellitus can impair wound healing due to poor circulation, neuropathy, and high blood sugar levels, which can lead to infection and delayed healing.

Question 17

The nurse is reviewing the medication list of a patient with impaired wound healing. Which medication would be of concern to the nurse?

Accepted Answer

Prednisone is a corticosteroid that can impair wound healing by reducing the inflammatory response and collagen synthesis.

Question 18

Which finding would the nurse expect when assessing a patient with a hypertrophic scar following second degree burns?

Accepted Answer

Hypertrophic scars are characterized by being raised above the surface of the surrounding skin but remain within the boundaries of the original injury.

Question 19

In evaluating the effectiveness of negative pressure wound therapy in patients with high-risk surgical wounds, the nurse should expect:

Accepted Answer

Negative pressure wound therapy is known to reduce the risk of wound dehiscence by promoting better wound closure and drainage.

Question 20

When assessing a wound in the remodeling phase of healing, the nurse would expect to find:

Accepted Answer

During the remodeling phase of wound healing, scar tissue formation occurs as the wound matures and strengthens.

Quiz 39: Tissue and Wound Healing