Skin Integrity and Wound Healing Questions With
Complete Solutions
The nurse is changing the dressing of a client with a gunshot
wound. What nursing action would the nurse provide?
- The nurse packs the wound cavity tightly with dressing
material.
- The nurse selects a dressing that absorbs exudate, if it is
present, but still maintains a moist environment.
- The nurse keeps the intact, healthy skin surrounding the ulcer
moist because it is susceptible to breakdown.
- The nurse uses wet-to-dry dressings continuously.
The nurse selects a dressing that absorbs exudate, if it is present,
but still maintains a moist environment.
Explanation:
A wound with heavy exudate will need a more absorptive
dressing and a dry wound will require rehydration with a
dressing that keeps the wound moist. The nurse would not keep
the surrounding tissue moist. The nurse would not pack the
wound cavity tightly, rather loosely. The nurse would not use
wet-to-dry dressings continuously.
,A client's pressure injury is superficial and presents clinically as
an abrasion, blister, or shallow crater. How would the nurse
document this pressure injury?
- Stage I
- Stage III
- Stage II
- Stage IV
Stage II
Explanation:
A stage II pressure injury involves partial thickness loss of
dermis and presents as a shallow, open ulcer. A stage II injury
could present as a blister, abrasion, or shallow crater. A stage I
pressure injury is a defined area of intact skin with
nonblanchable redness of a localized area, usually over a bony
prominence. Darkly pigmented skin may not have visible
blanching; its color may differ from the surrounding skin. The
area may be painful, firm, soft, warmer, or cooler as compared
to adjacent tissue. A stage III injury presents with full-thickness
tissue loss. Subcutaneous fat may be visible, but bone, tendon,
or muscle is not exposed. Slough that may be present does not
obscure the depth of tissue loss. Injuries at this stage may
include undermining and tunneling. Stage IV injuries involve
full-thickness tissue loss with exposed bone, tendon, or muscle.
,Slough or eschar may be present on some part of the wound bed
and often include undermining and tunneling.
The nurse considers the impact of shearing forces in the
development of pressure injuries in clients. Which client would
be most likely to develop a pressure injury from shearing
forces?
- a client who must remain on his back for long periods of time
- a client who lies on wrinkled sheets
- a client sitting in a chair who slides down
- a client who lifts himself up on his elbows
a client sitting in a chair who slides down
Explanation:
Shear results when one layer of tissue slides over another layer.
Shear separates the skin from underlying tissues. The small
blood vessels and capillaries in the area are stretched and
possibly tear, resulting in decreased circulation to the tissue cells
under the skin. Clients who are pulled, rather than lifted, when
being moved up in bed (or from bed to chair or stretcher) are at
risk for injury from shearing forces. A client who is partially
sitting up in bed is susceptible to shearing force when the skin
sticks to the sheet and underlying tissues move downward with
the body toward the foot of the bed. This may also occur in a
client who sits in a chair but slides down. The client that is most
likely to develop a pressure ulcer from shearing forces would be
a client sitting in a chair who slides down.
, The nurse is assessing the wounds of clients in a burn unit.
Which wound would most likely heal by primary intention?
- a wound healing naturally that becomes infected.
- a surgical incision with sutured approximated edges
- a wound left open for several days to allow edema to subside
- a large wound with considerable tissue loss allowed to heal
naturally
a surgical incision with sutured approximated edges
Explanation:
Wounds healed by primary intention are well approximated
(skin edges tightly together). Intentional wounds with minimal
tissue loss, such as those made by a surgical incision with
sutured approximated edges, usually heal by primary intention.
Wounds healed by secondary intention have edges that are not
well approximated. Large, open wounds, such as from burns or
major trauma, which require more tissue replacement and are
often contaminated, commonly heal by secondary intention. If a
wound that is healing by primary intention becomes infected, it
will heal by secondary intention. Wounds that heal by secondary
intention take longer to heal and form more scar tissue.
Connective tissue healing and repair follow the same phases in
healing. However, differences occur in the length of time
required for each phase and in the extent of new tissue formed.
Wounds healed by tertiary intention, or delayed primary closure,
are those wounds left open for several days to allow edema or
infection to resolve or fluid to drain, and then are closed.
Complete Solutions
The nurse is changing the dressing of a client with a gunshot
wound. What nursing action would the nurse provide?
- The nurse packs the wound cavity tightly with dressing
material.
- The nurse selects a dressing that absorbs exudate, if it is
present, but still maintains a moist environment.
- The nurse keeps the intact, healthy skin surrounding the ulcer
moist because it is susceptible to breakdown.
- The nurse uses wet-to-dry dressings continuously.
The nurse selects a dressing that absorbs exudate, if it is present,
but still maintains a moist environment.
Explanation:
A wound with heavy exudate will need a more absorptive
dressing and a dry wound will require rehydration with a
dressing that keeps the wound moist. The nurse would not keep
the surrounding tissue moist. The nurse would not pack the
wound cavity tightly, rather loosely. The nurse would not use
wet-to-dry dressings continuously.
,A client's pressure injury is superficial and presents clinically as
an abrasion, blister, or shallow crater. How would the nurse
document this pressure injury?
- Stage I
- Stage III
- Stage II
- Stage IV
Stage II
Explanation:
A stage II pressure injury involves partial thickness loss of
dermis and presents as a shallow, open ulcer. A stage II injury
could present as a blister, abrasion, or shallow crater. A stage I
pressure injury is a defined area of intact skin with
nonblanchable redness of a localized area, usually over a bony
prominence. Darkly pigmented skin may not have visible
blanching; its color may differ from the surrounding skin. The
area may be painful, firm, soft, warmer, or cooler as compared
to adjacent tissue. A stage III injury presents with full-thickness
tissue loss. Subcutaneous fat may be visible, but bone, tendon,
or muscle is not exposed. Slough that may be present does not
obscure the depth of tissue loss. Injuries at this stage may
include undermining and tunneling. Stage IV injuries involve
full-thickness tissue loss with exposed bone, tendon, or muscle.
,Slough or eschar may be present on some part of the wound bed
and often include undermining and tunneling.
The nurse considers the impact of shearing forces in the
development of pressure injuries in clients. Which client would
be most likely to develop a pressure injury from shearing
forces?
- a client who must remain on his back for long periods of time
- a client who lies on wrinkled sheets
- a client sitting in a chair who slides down
- a client who lifts himself up on his elbows
a client sitting in a chair who slides down
Explanation:
Shear results when one layer of tissue slides over another layer.
Shear separates the skin from underlying tissues. The small
blood vessels and capillaries in the area are stretched and
possibly tear, resulting in decreased circulation to the tissue cells
under the skin. Clients who are pulled, rather than lifted, when
being moved up in bed (or from bed to chair or stretcher) are at
risk for injury from shearing forces. A client who is partially
sitting up in bed is susceptible to shearing force when the skin
sticks to the sheet and underlying tissues move downward with
the body toward the foot of the bed. This may also occur in a
client who sits in a chair but slides down. The client that is most
likely to develop a pressure ulcer from shearing forces would be
a client sitting in a chair who slides down.
, The nurse is assessing the wounds of clients in a burn unit.
Which wound would most likely heal by primary intention?
- a wound healing naturally that becomes infected.
- a surgical incision with sutured approximated edges
- a wound left open for several days to allow edema to subside
- a large wound with considerable tissue loss allowed to heal
naturally
a surgical incision with sutured approximated edges
Explanation:
Wounds healed by primary intention are well approximated
(skin edges tightly together). Intentional wounds with minimal
tissue loss, such as those made by a surgical incision with
sutured approximated edges, usually heal by primary intention.
Wounds healed by secondary intention have edges that are not
well approximated. Large, open wounds, such as from burns or
major trauma, which require more tissue replacement and are
often contaminated, commonly heal by secondary intention. If a
wound that is healing by primary intention becomes infected, it
will heal by secondary intention. Wounds that heal by secondary
intention take longer to heal and form more scar tissue.
Connective tissue healing and repair follow the same phases in
healing. However, differences occur in the length of time
required for each phase and in the extent of new tissue formed.
Wounds healed by tertiary intention, or delayed primary closure,
are those wounds left open for several days to allow edema or
infection to resolve or fluid to drain, and then are closed.
