Question 1

A patient underwent abdominal surgery for a ruptured appendix.The surgeon did not surgically close the wound.The wound healing process described in this situation is:

Accepted Answer

Secondary intention healing occurs when a wound is left open,and it heals from the inner layer to the surface by filling in with beefy red granulation tissue.Primary intention healing occurs when a wound is surgically closed.Tertiary intention healing occurs when a wound that was previously left open to heal by secondary intention is closed by joining the margins of granulation tissue.Approximation is another word for the joining of wound edges.

Question 2

Which of the following describes the difference between dehiscence and evisceration?

Accepted Answer

With dehiscence,there is a separation of one or more layers of wound tissue,whereas evisceration involves the protrusion of internal viscera from the incision site.Evisceration is an urgent complication usually requiring immediate surgical intervention.

Question 3

Why might skin integrity and wound healing be compromised in the client who takes blood pressure medications? Antihypertensives:

Accepted Answer

Blood pressure medications decrease the amount of pressure required to occlude blood flow to an area,creating a risk for ischemia.Chemotherapeutic agents delay wound healing because of their cellular toxicity.Anticoagulants can lead to extravasation of blood into subcutaneous tissue,predisposing to hematoma formation with minimal pressure or injury.

Question 4

What intervention would be most appropriate for a wound with a beefy red wound bed?

Accepted Answer

A red wound indicates active healing,and the best treatment is gentle cleansing and a dressing that will ensure a clean,moist wound environment.Debridement is not necessary in this situation because there is no devitalized tissue present.

Question 5

Why is the information obtained from a swab culture of a wound limited?

Accepted Answer

The information obtained from a swab culture is limited because a positive culture may not indicate infection.Chronic wounds are often colonized with bacteria,but this does not require antibiotic treatment.A needle aspiration of the wound would provide more definitive information about whether the wound is infected or not and can be performed by a registered nurse.However,the most accurate wound information is obtained by tissue biopsy performed by a specially trained provider.

Question 6

Pressure ulcers are directly caused by which of the following conditions at the site?

Accepted Answer

Pressure ulcers are caused by unrelieved pressure that compromises blood flow to an area,resulting in ischemia (inadequate blood supply)in the underlying tissue.Friction and shear are extrinsic factors affecting skin integrity,which increases the risk of a client developing a pressure ulcer but is not the direct cause.Inadequate arterial blood flow to an area as a result of pressure causes the development of a pressure ulcer.Edema leads to compromised skin and tissue integrity,which is more prone to pressure injury.

Question 7

A man was involved in a motor vehicle accident yesterday.He is to be sedated for more than 2 weeks while breathing with the assistance of a mechanical ventilator.Which of the following would be an appropriate nursing diagnosis for him at this time?

Accepted Answer

This patient is at Risk for Impaired Skin Integrity because he is being kept in a sedated state.Thus,he is unable to turn himself to relieve pressure.There is no mention of subcutaneous injuries,ruling out Risk for Infection related to subcutaneous injuries.Impaired Tissue Integrity and Impaired Skin Integrity are also incorrect because there is no supporting evidence for these nursing diagnoses.

Question 8

For the client with a stage IV pressure ulcer,what would an applicable patient goal/outcome be?

Accepted Answer

The goal for any wound is for healing to take place with no complications (such as infection).Intact skin throughout hospitalization is not realistic with a stage IV pressure ulcer.Limiting pressure to a wound site is incorrect because total pressure relief must be provided to the area.Improved wound drainage before discharge is not a realistic expectation for a stage IV pressure ulcer.

Question 9

When teaching a patient about the healing process of an open wound after surgery,which of the following points would the nurse make?

Accepted Answer

Because the wound edges are not approximated,more scar tissue will form.Although open wounds are more prone to infection,this is not an expected outcome,and antibiotics would not necessarily be needed.A patient with an open wound should not expect an extended hospital stay if wound care can be provided in the home or an outpatient setting.

Question 10

A patient had a CVA (stroke)2 days ago,resulting in decreased mobility to her left side.During the assessment,the nurse discovers a stage I pressure area on the patient's left heel.What is the initial treatment for this pressure ulcer?

Accepted Answer

Pressure ulcers are caused by pressure to an area that restricts blood flow,causing ischemia to underlying tissue.The primary treatment is to relieve the pressure,thus improving blood flow.Elevating the patient's left heel off the bed would relieve pressure to this area.Antibiotics treat infection; a stage I pressure injury is not infected.Skin of a stage I pressure wound is intact but has nonblanchable redness; therefore,irrigation is not indicated for stage I pressure wounds.The area may be painful,firm,soft,or warmer or cooler as compared with adjacent tissue,but is not deep enough for debridement.

Question 11

A patient has underlying cardiac disease and requires careful monitoring of his fluid balance.He also has a draining wound.Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss?

Accepted Answer

By weighing the dressing before it is applied and after it is removed,the nurse can accurately determine the amount of drainage.Weighing the patient daily would evaluate his overall fluid balance but is not sensitive to fluid loss through the wound.Marking a circle around the wound is useful for determining the extent of drainage seeping out of a wound but it does not provide information on how much fluid is draining.

Question 12

What is the function of the stratum corneum?

Accepted Answer

The stratum corneum is the outermost layer of the epidermis and is composed of numerous thicknesses of dead cells.Functioning as a barrier to the environment,it restricts water loss,prevents entry of fluids into the body,and protects the body against the entry of pathogens and chemicals.The subcutaneous layer is composed of adipose and connective tissue that provide insulation,protection,and an energy reserve (adipose).The dermis is composed of irregular fibrous connective tissue that provides strength and elasticity to the skin.The stratum germinativum is the innermost layer of the skin that produces new cells,pushing older cells toward the skin surface.

Question 13

What is the primary goal that the nurse should establish for a patient with an open wound?

Accepted Answer

Wounds healing by secondary intention are more prone to infection; therefore,the primary goal is to prevent infection.Antibiotics may not be necessary,and the nurse can expect the formation of scar tissue in this particular situation.There is no evidence presented that the patient needs to increase caloric intake.

Question 14

A patient has a stage II pressure ulcer on her right buttock.The ulcer is covered with dry,yellow slough that tightly adheres to the wound.What is the best treatment the nurse could recommend for treating this wound?

Accepted Answer

A hydrocolloid dressing would conform to this area and form a protective layer against friction and bacterial invasion.It would also promote autolytic debridement of the slough and absorb the exudate from the autolysis.Dry gauze and nonadherent dressing (e.g.,Telfa)would cover the wound but would not aid in removing the slough.A wet-to-dry dressing is a form of mechanical debridement.It would aid in removing the slough but is nonselective; therefore,it could cause damage to healthy tissue as well.

Question 15

A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago,and now the ulcer appears to be a shallow crater involving only partial skin loss.What would the nurse now classify the pressure ulcer as?

Accepted Answer

Reverse staging is not done because,as the ulcer heals with granulation tissue and becomes shallower,the lost muscle,subcutaneous fat,and dermis are not replaced.Pressure ulcers maintain their original staging classification throughout the healing process but are accompanied by the modifier healing.

Question 16

A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis.When documenting the depth of the wound,how would the nurse classify it?

Accepted Answer

Partial-thickness wounds extend through the epidermis into the dermis.Superficial wounds involve only the epidermal layer of skin.Full-thickness wounds extend into the subcutaneous tissue and beyond.Penetrating is a descriptor sometimes added to indicate that the wound includes internal organs.

Question 17

The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client

Accepted Answer

Diabetic clients experiencing difficulty with blood sugar control are prone to the development of peripheral neuropathy,which results in decreased sensation in the feet and lower extremities.Decreased sensation in the feet places the client at increased risk for development of wounds or pressure ulcers in the feet.The nurse will know this plan of care is effective when the client's feet remain free of wounds.An aggressive exercise program would not be appropriate for a client with severely diminished sensation in the feet.Similarly,a 1,200-calorie diet would be inadequate for most clients.Being fitted for diabetic footwear is an intervention rather than a goal.

Question 18

What is the primary difference between acute and chronic wounds? Chronic wounds:

Accepted Answer

The length of time for healing is the determining factor when classifying a wound as acute or chronic.Acute wounds are expected to be of short duration.Wounds that exceed the anticipated length of recovery are classified as chronic wounds.

Question 19

A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy.She has a pressure area on her coccyx measuring 5 cm by 3 cm.The area is covered with 100% eschar.What would the nurse identify this as?

Accepted Answer

An eschar is a black,leathery covering made up of necrotic tissue.An ulcer covered in eschar cannot be classified using a staging method because it is impossible to determine the depth.

Question 20

While assessing a new wound,the nurse notes red,watery drainage.How should the nurse describe this type of drainage when documenting?

Accepted Answer

Serosanguineous drainage,a combination of bloody and serous drainage,is most commonly seen with new wounds.Serous drainage is straw colored,and sanguineous drainage is bloody.Purosanguineous drainage is pus that is red tinged.

Quiz 35: Skin Integrity-Wound Healing