NUR 204 EXAM 2 QUESTIONS WITH ACCURATE SOLUTIONS
What are the stages of wound healing? -- Answer ✔✔ 1. inflammatory
2. proliferative
3. maturation/remodeling
What is the inflammatory stage of wound healing? -- Answer ✔✔ begins with injury,
lasts 3-6 days
control bleeding (vasoconstriction, blood vessel retraction, fibrin accumulation, clot
formation)
deliver O2, WBC, and nutrients
macrophages, phagocytosis
What is the proliferative stage of wound healing? -- Answer ✔✔ lasts the next 3-24 days
replace lost tissue w/ connective or granulated tissue and collagen
contract wound's edges to reduce area that requires healing
resurfacing of new epithelial cells
What is the maturation or remodeling stage of wound healing? -- Answer ✔✔ occurs
on/about day 21
strengthening of collagen scar and restoration of more normal appearance
can take > 1 year to complete depending on original wound extent
What are the phases of healing process? -- Answer ✔✔ 1. primary intention
2. secondary intention
3. tertiary intention
What occurs during primary intention? -- Answer ✔✔ -little/no tissue loss
-edges approximated (eg w/in surgical incision)
-heals rapidly
-low risk of infection
,-no/minimal scarring
eg = closed surgical incision w/ staples, sutures, or liquid glue to seal laceration
What occurs during secondary intention? -- Answer ✔✔ -loss of tissue
-wound edges widely separated, unapproximated (eg = pressure injury, open burn areas)
-longer healing time
-increase for risk of infection
-scarring
-heals by granulation
eg = pressure injury left open to heal
What occurs during tertiary intention? -- Answer ✔✔ -widely separated
-deep
-spontaneous opening of a previously closed wound
-closure of wounds occurs when they are free of infection and edema
-risk of infection
-extensive drainage/tissue debris
-closed later
-long healing time
eg = abdominal wound initially left open until infection is resolved and then closed
What factors affect wound healing? -- Answer ✔✔ 1. age
2. overall wellness
3. decreased leukocyte count
4. infection
5. some medications
6. malnourished clients
7. tissue perfusion
8. low Hgb levels
9. obesity
10. chronic diseases
11. smoking
12. wound stress
, What are indications of sepsis? -- Answer ✔✔ 1. changes in LOC
2. persistent recurrent fever
3. tachycardia
4. tachypnea
5. hypotension. 6. oliguria
7. increased WBC count
What is a problem-centered nursing diagnosis? -- Answer ✔✔ problem-focused
diagnosis r/t______ aeb ________
eg = anxiety r/t situational crises and stress aeb restlessness, insomnia, anguish, and
anorexia
What is a risk nursing diagnosis? -- Answer ✔✔ risk for _______aeb_______
**NO related factors
eg = risk for infection aeb inadequate vaccination and immunosuppression
What is a health promotion nursing diagnosis? -- Answer ✔✔ readiness for enhanced
self-care aeb enhanced desire to enhance self-care
**NO related factors
What is the purpose of evaluation in the nursing process? -- Answer ✔✔ -to see if the
goals were met
-to see status of pt in regards to the problem
-did the clients well being and/or condition improve
-adjust interventions and begin process again if goals unmet
-care plan revision
What does the patient's problem help RN do? -- Answer ✔✔ develop care plan with
nursing diagnoses
What are tools used for risk assessment of pressure injury? -- Answer ✔✔ Braden scale
Norton scale
What are 11 factors that affect skin integrity? -- Answer ✔✔ 1. age
What are the stages of wound healing? -- Answer ✔✔ 1. inflammatory
2. proliferative
3. maturation/remodeling
What is the inflammatory stage of wound healing? -- Answer ✔✔ begins with injury,
lasts 3-6 days
control bleeding (vasoconstriction, blood vessel retraction, fibrin accumulation, clot
formation)
deliver O2, WBC, and nutrients
macrophages, phagocytosis
What is the proliferative stage of wound healing? -- Answer ✔✔ lasts the next 3-24 days
replace lost tissue w/ connective or granulated tissue and collagen
contract wound's edges to reduce area that requires healing
resurfacing of new epithelial cells
What is the maturation or remodeling stage of wound healing? -- Answer ✔✔ occurs
on/about day 21
strengthening of collagen scar and restoration of more normal appearance
can take > 1 year to complete depending on original wound extent
What are the phases of healing process? -- Answer ✔✔ 1. primary intention
2. secondary intention
3. tertiary intention
What occurs during primary intention? -- Answer ✔✔ -little/no tissue loss
-edges approximated (eg w/in surgical incision)
-heals rapidly
-low risk of infection
,-no/minimal scarring
eg = closed surgical incision w/ staples, sutures, or liquid glue to seal laceration
What occurs during secondary intention? -- Answer ✔✔ -loss of tissue
-wound edges widely separated, unapproximated (eg = pressure injury, open burn areas)
-longer healing time
-increase for risk of infection
-scarring
-heals by granulation
eg = pressure injury left open to heal
What occurs during tertiary intention? -- Answer ✔✔ -widely separated
-deep
-spontaneous opening of a previously closed wound
-closure of wounds occurs when they are free of infection and edema
-risk of infection
-extensive drainage/tissue debris
-closed later
-long healing time
eg = abdominal wound initially left open until infection is resolved and then closed
What factors affect wound healing? -- Answer ✔✔ 1. age
2. overall wellness
3. decreased leukocyte count
4. infection
5. some medications
6. malnourished clients
7. tissue perfusion
8. low Hgb levels
9. obesity
10. chronic diseases
11. smoking
12. wound stress
, What are indications of sepsis? -- Answer ✔✔ 1. changes in LOC
2. persistent recurrent fever
3. tachycardia
4. tachypnea
5. hypotension. 6. oliguria
7. increased WBC count
What is a problem-centered nursing diagnosis? -- Answer ✔✔ problem-focused
diagnosis r/t______ aeb ________
eg = anxiety r/t situational crises and stress aeb restlessness, insomnia, anguish, and
anorexia
What is a risk nursing diagnosis? -- Answer ✔✔ risk for _______aeb_______
**NO related factors
eg = risk for infection aeb inadequate vaccination and immunosuppression
What is a health promotion nursing diagnosis? -- Answer ✔✔ readiness for enhanced
self-care aeb enhanced desire to enhance self-care
**NO related factors
What is the purpose of evaluation in the nursing process? -- Answer ✔✔ -to see if the
goals were met
-to see status of pt in regards to the problem
-did the clients well being and/or condition improve
-adjust interventions and begin process again if goals unmet
-care plan revision
What does the patient's problem help RN do? -- Answer ✔✔ develop care plan with
nursing diagnoses
What are tools used for risk assessment of pressure injury? -- Answer ✔✔ Braden scale
Norton scale
What are 11 factors that affect skin integrity? -- Answer ✔✔ 1. age
