Chapter 36: Skin Integrity and Wound Healing Test Bank Questions And Verified Accurate Answers| Already Graded A+.

What is the function of the stratum corneum? a) Provides insulation for temperature regulation b) Provides strength and elasticity to the skin c) Protects the body against the entry of pathogens d) Continually produces new skin cells - correct answer c) Protects the body against the entry of pathogens Skin integrity and wound healing are compromised in the client who takes blood pressure medications because antihypertensives: a) Can cause cellular toxicity b) Increase the risk of ischemia c) Delay wound healing d) Predispose to hematoma formation - correct answer b) Increase the risk of ischemia What is the primary difference between acute and chronic wounds? Chronic wounds: a) Are full-thickness wounds, but acute wounds are superficial b) Result from pressure, but acute wounds result from surgery c) Are usually infected, whereas acute wounds are contaminated d) Exceed the typical healing time, but acute wounds heal readily - correct answer d) Exceed the typical healing time, but acute wounds heal readily 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? a) Partial-thickness wound b) Penetrating wound c) Superficial wound d) Full-thickness wound - correct answer a) Partial-thickness wound 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: a) Primary intention healing b) Secondary intention healing c) Tertiary intention healing d) Approximation healing - correct answer b) Secondary intention healing When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make? a) The patient will need to take antibiotics until the wound is completely healed b) Because the patients wound was left open, the wound will likely become infected c) The patient will have more scar tissue formation than for a wound closed at surgery d) The patient should expect to remain hospitalized until complete wound healing occurs - correct answer c) The patient will have more scar tissue formation than for a wound closed at surgery What is the primary goal that the nurse should establish for a patient with an open wound? a) The wound will remain free of infection throughout the healing process b) Client completes antibiotic treatment as ordered c) The wound will remain free of scar tissue at healing d) Client increases caloric intake throughout the healing process - correct answer a) The wound will remain free of infection throughout the healing process While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as? a) Sanguineous b) Serosanguineous c) Serous d) Purosanguineous - correct answer b) Serosanguineous Three days after a patient had abdominal surgery, the nurse notes a 4-cm periwound erythema and swelling at the distal end of the incision. The area is tender and warm to the touch. Staples are intact along the incision, and there is no obvious drainage. Heart rate is 96 beats/min and oral temperature is 100.8F (38.2C). The nurse would suspect that the patient has what kind of complication? a) Infection at the incisional site b) Dehiscence of the wound c) Hematoma under the skin d) Formation of granulation tissue - correct answer a) Infection at the incisional site Which of the following describes the difference between dehiscence and evisceration? a) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site b) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent c) Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue d) Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue - correct answer a) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client: a) begins an aggressive exercise program b) follows a diet plan of 1,200 calories per day c) is fitted for deep-depth diabetic footwear d) remains free of foot wounds - correct answer d) remains free of foot wounds Pressure ulcers are directly caused by which of the following conditions at the site a) Compromised blood flow b) Edema c) Shearing forces d) Inadequate venous return - correct answer a) Compromised blood flow 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? a) Stage II pressure ulcer b) Stage III pressure ulcer c) Stage IV pressure ulcer d) Unstageable pressure ulcer - correct answer d) Unstageable pressure ulcer 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? a) Stage I pressure ulcer, healing b) Stage II pressure ulcer, healing c) Stage III pressure ulcer, healing d) Stage IV pressure ulcer, healing - correct answer d) Stage IV pressure ulcer, healing 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? a) Draw a circle around the area of drainage on a dressing b) Classify drainage as less or more than the previous drainage c) Weigh the patient at the same time each day on the same scale d) Weigh dressings before they are applied and after they are removed - correct answer d) Weigh dressings before they are applied and after they are removed 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 patients left heel. What is the initial treatment for this pressure ulcer? a) Antibiotic therapy for 2 weeks b) Normal saline irrigation of the ulcer daily c) Debridement to the left heel d) Elevation of the left heel off the bed - correct answer d) Elevation of the left heel off the bed Why is the information obtained from a swab culture of a wound limited? a) A positive culture does not necessarily indicate infection, because chronic wounds are often colonized with bacteria b) A negative culture may not indicate infection, because chronic wounds are often colonized with bacteria c) Most wound infections are viral, so the swab culture would not be indicative of a wound infection d) A swab culture result does not include bacterial sensitivity information necessary to provide treatment - correct answer a) A positive culture does not necessarily indicate infection, because chronic wounds are often colonized with bacteria For the client with a stage IV pressure ulcer, what would an applicable patient goal/outcome be? a) Client will maintain intact skin throughout hospitalization b) Client will limit pressure to wound site throughout treatment course c) Wound will close with no evidence of infection within 6 weeks d) Wound will improve prior to discharge as evidenced by a decrease in drainage - correct answer c) Wound will close with no evidence of infection within 6 weeks A man was involved in a motor vehicle accident yesterday. He is to be sedated for over 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? a) Risk for Infection related to subcutaneous injuries b) Risk for Impaired Skin Integrity related to immobility c) Impaired Tissue Integrity related to ventilator dependency d) Impaired Skin Integrity related to ventilator dependency - correct answer b) Risk for Impaired Skin Integrity related to immobility What intervention would be most appropriate for a wound with a beefy red wound bed? a) Mechanical debridement b) Autolytic debridement c) Dressing to keep the wound moist and clean d) Removal of devitalized tissue and a sterile dressing - correct answer c) Dressing to keep the wound moist and clean 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? a) Dry gauze dressing changed twice daily b) Nonadherent dressing with daily wound care c) Hydrocolloid dressing changed as needed d) Wet-to-dry dressings changed three times a day - correct answer c) Hydrocolloid dressing changed as needed The nurse would know care for a stage II pressure ulcer is achieving the desired goal when: a) The ulcer is completely healed with minimal scarring b) The patient reports no pain at the site c) A minimal amount of drainage is noted d) The wound bed contains 100% granulated tissue - correct answer d) The wound bed contains 100% granulated tissue Your patient has a deep wound on the right hip, with tunneling at the 8 oclock position extending 5 cm. The wound is draining large amounts of serosanguineous fluid and contains 100% red beefy tissue in the wound bed. Of the following, which would be an appropriate dressing choice? a) Alginate dressing b) Dry gauze dressing c) Hydrogel d) Hydrocolloid dressing - correct answer a) Alginate dressing Of the following, which is the best choice for performing wound irrigation?