Florida International University NUR 3029: Fundamentals
"Skin Integrity and Wound Care: Chapter 48" (Potter &
Perry Skin Integrity and Wound Care Chapter - Pressure
ulcer: risk, assessment, management, evaluation - Wound
healing process - Complications of wound healing - Wound
drainage management - Clarifications of pressure ulcers)
Questions With Complete Solutions
_____ assessments and __________ assessments provide
valuable data that indicate skin integrity, as well as any risk for
pressure ulcer development Correct Answer baseline,
continual
_____ enables you to use palpation to acquire further data about
indurations and damage to the skin and underlying tissues
Correct Answer tactile assessment
_____ thickness wounds heal via inflammatory response,
proliferation, and remodeling Correct Answer full
________ _______ is a force that acts perpendicular to the plane
of interaction Correct Answer shearing force
________ thickness will heal via the inflammatory response,
epithelial proliferation, and migration with reestablishement of
epidermal layers Correct Answer partial
_________ or _________ the final stage of healing, sometimes
takes place for longer than a year, depending on the depth and
extent of the wound Correct Answer remodeling, maturation
,A 40-year-old client is a new paraplegic. The client is about to
be discharged from the rehabilitation center. Prevention of
pressure ulcers has been an important part of the client's
education. In providing this education, the nurse should have
included which of the following guidelines?
A) The client should sit in chair for no longer than 3 hours.
B) The client should use a donut-shaped chair cushion.
C) The client should use a rigid cushion for full support.
D) The client should shift the weight in a chair every 15
minutes. Correct Answer D) The client should shift the weight
in a chair every 15 minutes.
a localized collection of blood underneath the tissues Correct
Answer hematoma
a low _____ level decreases delivery of oxygen to the tissues
and leads to further ischemia Correct Answer hemoglobin
a partial or total separation of wound layers Correct Answer
dehiscence
a patient care lose as much as _____ of protein per day from an
open, weeping pressure ulcer Correct Answer 50g
A patient has developed a decubitus ulcer. What laboratory data
would be important to gather?
A. Serum albumin
B. Creatine kinase
C. Vitamin E
,D. Potassium Correct Answer A. Serum albumin
Normal wound healing requires proper nutrition. Serum proteins
are biochemical indicators of malnutrition, and serum albumin is
probably the most frequently measured of these parameters. The
best measurement of nutritional status is prealbumin because it
reflects not only what the patient has ingested, but also what the
body has absorbed, digested, and metabolized. Measurement of
creatine kinase helps in the diagnosis of myocardial infarcts and
has no known role in wound healing. Potassium is a major
electrolyte that helps to regulate metabolic activities, cardiac
muscle contraction, skeletal and smooth muscle contraction, and
transmission and conduction of nerve impulses. Vitamin E is a
fat-soluble vitamin that prevents the oxidation of unsaturated
fatty acids. It is believed to reduce the risk of coronary artery
disease and cancer. Vitamin E has no known role in wound
healing.
A patient presents to the emergency department with a
laceration of the right forearm caused by a fall. After
determining that the patient is stable, the next best step is to:
A. Inspect the wound for bleeding
B. Inspect the wound for foreign bodies
C. Determine the size of the wound
D. Determine the need for a tetanus antitoxin injection Correct
Answer A. Inspect the wound for bleeding
After determining that a patient's condition is stable, inspect the
wound for bleeding. An abrasion will have limited bleeding, a
laceration can bleed more profusely, and a puncture wound
, bleeds in relation to the size and depth of the wound. Address
any bleeding issues. Inspect the wound for foreign bodies;
traumatic wounds are dirty and may need to be addressed.
Determine the size of the wound. A large open wound may
expose bone or tissue and be protected, or the wound may need
suturing. When the wound is caused by a dirty penetrating
object, determine the need for a tetanus vaccination.
a patient who is at risk for poor wound healing is at risk for
Correct Answer dehiscence
a series of events designed to control blood loss, establish
bacterial control, and seal the defect that results when an injury
occurs Correct Answer hemostasis
a wound involving loss of tissue such as a burn, pressure ulcer,
or severe laceration heals by Correct Answer secondary
intention
abnormal reactive hyperemia are early signs are indicators of
Correct Answer impaired skin integrity (but damage to the
underlying tissue is sometimes more progressive)
An adolescent client who has diabetes mellitus is 2 days
postoperative following an appendectomy. The client is
tolerating a regular diet well. He has ambulated successfully
around the unit with assistance and requests pain medication
every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10
after medication is given. His incision is approximated and free
of redness with scant serous drainage noted on the dressing.
"Skin Integrity and Wound Care: Chapter 48" (Potter &
Perry Skin Integrity and Wound Care Chapter - Pressure
ulcer: risk, assessment, management, evaluation - Wound
healing process - Complications of wound healing - Wound
drainage management - Clarifications of pressure ulcers)
Questions With Complete Solutions
_____ assessments and __________ assessments provide
valuable data that indicate skin integrity, as well as any risk for
pressure ulcer development Correct Answer baseline,
continual
_____ enables you to use palpation to acquire further data about
indurations and damage to the skin and underlying tissues
Correct Answer tactile assessment
_____ thickness wounds heal via inflammatory response,
proliferation, and remodeling Correct Answer full
________ _______ is a force that acts perpendicular to the plane
of interaction Correct Answer shearing force
________ thickness will heal via the inflammatory response,
epithelial proliferation, and migration with reestablishement of
epidermal layers Correct Answer partial
_________ or _________ the final stage of healing, sometimes
takes place for longer than a year, depending on the depth and
extent of the wound Correct Answer remodeling, maturation
,A 40-year-old client is a new paraplegic. The client is about to
be discharged from the rehabilitation center. Prevention of
pressure ulcers has been an important part of the client's
education. In providing this education, the nurse should have
included which of the following guidelines?
A) The client should sit in chair for no longer than 3 hours.
B) The client should use a donut-shaped chair cushion.
C) The client should use a rigid cushion for full support.
D) The client should shift the weight in a chair every 15
minutes. Correct Answer D) The client should shift the weight
in a chair every 15 minutes.
a localized collection of blood underneath the tissues Correct
Answer hematoma
a low _____ level decreases delivery of oxygen to the tissues
and leads to further ischemia Correct Answer hemoglobin
a partial or total separation of wound layers Correct Answer
dehiscence
a patient care lose as much as _____ of protein per day from an
open, weeping pressure ulcer Correct Answer 50g
A patient has developed a decubitus ulcer. What laboratory data
would be important to gather?
A. Serum albumin
B. Creatine kinase
C. Vitamin E
,D. Potassium Correct Answer A. Serum albumin
Normal wound healing requires proper nutrition. Serum proteins
are biochemical indicators of malnutrition, and serum albumin is
probably the most frequently measured of these parameters. The
best measurement of nutritional status is prealbumin because it
reflects not only what the patient has ingested, but also what the
body has absorbed, digested, and metabolized. Measurement of
creatine kinase helps in the diagnosis of myocardial infarcts and
has no known role in wound healing. Potassium is a major
electrolyte that helps to regulate metabolic activities, cardiac
muscle contraction, skeletal and smooth muscle contraction, and
transmission and conduction of nerve impulses. Vitamin E is a
fat-soluble vitamin that prevents the oxidation of unsaturated
fatty acids. It is believed to reduce the risk of coronary artery
disease and cancer. Vitamin E has no known role in wound
healing.
A patient presents to the emergency department with a
laceration of the right forearm caused by a fall. After
determining that the patient is stable, the next best step is to:
A. Inspect the wound for bleeding
B. Inspect the wound for foreign bodies
C. Determine the size of the wound
D. Determine the need for a tetanus antitoxin injection Correct
Answer A. Inspect the wound for bleeding
After determining that a patient's condition is stable, inspect the
wound for bleeding. An abrasion will have limited bleeding, a
laceration can bleed more profusely, and a puncture wound
, bleeds in relation to the size and depth of the wound. Address
any bleeding issues. Inspect the wound for foreign bodies;
traumatic wounds are dirty and may need to be addressed.
Determine the size of the wound. A large open wound may
expose bone or tissue and be protected, or the wound may need
suturing. When the wound is caused by a dirty penetrating
object, determine the need for a tetanus vaccination.
a patient who is at risk for poor wound healing is at risk for
Correct Answer dehiscence
a series of events designed to control blood loss, establish
bacterial control, and seal the defect that results when an injury
occurs Correct Answer hemostasis
a wound involving loss of tissue such as a burn, pressure ulcer,
or severe laceration heals by Correct Answer secondary
intention
abnormal reactive hyperemia are early signs are indicators of
Correct Answer impaired skin integrity (but damage to the
underlying tissue is sometimes more progressive)
An adolescent client who has diabetes mellitus is 2 days
postoperative following an appendectomy. The client is
tolerating a regular diet well. He has ambulated successfully
around the unit with assistance and requests pain medication
every 6 to 8 hr while reporting pain at a 2 on a scale of 0 to 10
after medication is given. His incision is approximated and free
of redness with scant serous drainage noted on the dressing.
