NU 136, Galen College of Nursing,
Exam 2, Units 4-6, Chapters 22, 28, 39,
29, 30, 38 Study Guide Exam and
Actual Answers.
what are the locations for arterial ulcers - Answer -between toes
-tips of toes
-over phalangeal heads
-around lateral malleolus
what are the characteristics of arterial ulcers - Answer -severe pain
-minimal drainage
-decreased temperature
-absent or diminished pulses
-cyanosis
-thickened toenails
-gangrene
what are the locations for venous ulcers - Answer -medial lower leg
-ankle
-superior to medial melleolus
-seldom, if ever noted on the foot or above the knee
what are the characteristics of venous ulcers - Answer -moderate to large amount of
drainage
-pain levels vary
-ankle flare
-lipodermatosclerosis (hard fibrous of surrounding tissue)
-dialated superficial veins
what are the location for neuropathic (Diabetic) ulcers - Answer -plantar aspect of foot
-over metatarsal heads
-under heel
what are the characteristics for neuropathic ulcers - Answer -low to moderate drainage
,-foot deformities
-deminished or absent sensation in foot
-palpable pulses
-osteomyelitis
-usually painless
what are the phases of wound healing - Answer hemostatis
inflammation
proliferation
maturation
what phase is the hemostasis - Answer phase 1 -the immediate response the body initiates
to heal (blood clotting)
what phase is the inflammation - Answer phase 2 - begins immediately and last 4-5 days, it is
the protective response (heat, pain, edema) wbc & macrophages migrate to the wound & begin
the repair
what phase is the proliferation - Answer phase 3 - reconstructive phase - begins on 3rd or
4th day and lasts 2-3 weeks
what phase is the maturation phase - Answer phase 4 - final phase/remodeling phase - scar
maturation, scar slowly thins and becomes paler - begins about 3 weeks after injury and can last
up to 2 years
what factors affect wound healing - Answer -age
-nutrition (protein/fluid needed for healing)
-medications (heparin, steroids, antineoplastics interfere
w/healing
-Infection (slows healing) chronic illness (COPD, DM, CV)
slows wound healing due to lack of oxygen & nutrients at
the cellular level
-lifestyle (regular exercise)
-decreased immune system
-decreased liver function
,what is first intention (Primary) - Answer little tissue loss - edges of wound approximate and
only a slight chance of infection
what is second intention - Answer a wound with tissue loss - edges of wound do not
approximate;wound left open & fills with scar tissue
what is third intention (Tertiary) - Answer occurs when there is delayed suturing of a
wound/wound sutured after granulation tissue begins to form. (Healing.)
what are the closed wounds and characteristics - Answer -contusion (bruise w/out breaking
skin)
-hematoma (pooling of blood under unbroken skin)
-sprain (twisting of a joint)
what are the open wounds and characteristics - Answer -incision (surgically made separation
of tissues w/clean
even edges)
-laceration (traumatic separation of tissue)
-abrasion (traumatic scraping)
-penetrating (bullet/metal)
-avulsion (tearing away)
-ulceration (excavation of skin
-perforation (internal organ/cavity)
-crush (tissue disrupted or compressed
list complications of wound healing - Answer -hemorrhage (uncontrolled bleeding)
-dehiscence (spontaneous opening of an incision)
-evisceration (protrusion of an internal organ through an
incision)
-infection (redness, edema, pain, purulent drainage)
what is the purpose of wound drains - Answer to provide an exit for blood & pus that
accumulate during the inflammation process
how does an active drain work - Answer it is attached to a wound suction device to remove
any accumulated exudate or other material
(ex. Hemovac & Jackson-Pratt)
, how does a passive drain work - Answer it has no suction device, it works by the increased
pressure inside the wound & depends on gravity & capillary action to pull out any fluid buildup
(Penrose)
what do you assess with drainage - Answer color
consistency
odor
amount
what are the advantages of negative pressure wound therapy (wound vac) - Answer -
increase healing rate by 40%
-increases blood flow to wound
-less frequent dressing changes
-improved tissue growth
-draws out fluid
what is negative pressure wound therapy - Answer vacuum assisted closure involves
applying a suction device to a special dressing to institute negative pressure at the site, drawing
the edges together, a mechanical stretch of cells occur which increases cellular proliferation and
tissue growth
a cold compress can be on no longer than____________________________ - Answer 20
minutes
what is the most common place for neuropathic ulcers - Answer metatarsals
what is charcot foot - Answer when the arch collapses and causes an ulcer
what do you assess about a wound - Answer the skin around it for:
edema
erythema
temp
what are types of wound closures - Answer sutures
staples
steri-strips (if wound is small)
Exam 2, Units 4-6, Chapters 22, 28, 39,
29, 30, 38 Study Guide Exam and
Actual Answers.
what are the locations for arterial ulcers - Answer -between toes
-tips of toes
-over phalangeal heads
-around lateral malleolus
what are the characteristics of arterial ulcers - Answer -severe pain
-minimal drainage
-decreased temperature
-absent or diminished pulses
-cyanosis
-thickened toenails
-gangrene
what are the locations for venous ulcers - Answer -medial lower leg
-ankle
-superior to medial melleolus
-seldom, if ever noted on the foot or above the knee
what are the characteristics of venous ulcers - Answer -moderate to large amount of
drainage
-pain levels vary
-ankle flare
-lipodermatosclerosis (hard fibrous of surrounding tissue)
-dialated superficial veins
what are the location for neuropathic (Diabetic) ulcers - Answer -plantar aspect of foot
-over metatarsal heads
-under heel
what are the characteristics for neuropathic ulcers - Answer -low to moderate drainage
,-foot deformities
-deminished or absent sensation in foot
-palpable pulses
-osteomyelitis
-usually painless
what are the phases of wound healing - Answer hemostatis
inflammation
proliferation
maturation
what phase is the hemostasis - Answer phase 1 -the immediate response the body initiates
to heal (blood clotting)
what phase is the inflammation - Answer phase 2 - begins immediately and last 4-5 days, it is
the protective response (heat, pain, edema) wbc & macrophages migrate to the wound & begin
the repair
what phase is the proliferation - Answer phase 3 - reconstructive phase - begins on 3rd or
4th day and lasts 2-3 weeks
what phase is the maturation phase - Answer phase 4 - final phase/remodeling phase - scar
maturation, scar slowly thins and becomes paler - begins about 3 weeks after injury and can last
up to 2 years
what factors affect wound healing - Answer -age
-nutrition (protein/fluid needed for healing)
-medications (heparin, steroids, antineoplastics interfere
w/healing
-Infection (slows healing) chronic illness (COPD, DM, CV)
slows wound healing due to lack of oxygen & nutrients at
the cellular level
-lifestyle (regular exercise)
-decreased immune system
-decreased liver function
,what is first intention (Primary) - Answer little tissue loss - edges of wound approximate and
only a slight chance of infection
what is second intention - Answer a wound with tissue loss - edges of wound do not
approximate;wound left open & fills with scar tissue
what is third intention (Tertiary) - Answer occurs when there is delayed suturing of a
wound/wound sutured after granulation tissue begins to form. (Healing.)
what are the closed wounds and characteristics - Answer -contusion (bruise w/out breaking
skin)
-hematoma (pooling of blood under unbroken skin)
-sprain (twisting of a joint)
what are the open wounds and characteristics - Answer -incision (surgically made separation
of tissues w/clean
even edges)
-laceration (traumatic separation of tissue)
-abrasion (traumatic scraping)
-penetrating (bullet/metal)
-avulsion (tearing away)
-ulceration (excavation of skin
-perforation (internal organ/cavity)
-crush (tissue disrupted or compressed
list complications of wound healing - Answer -hemorrhage (uncontrolled bleeding)
-dehiscence (spontaneous opening of an incision)
-evisceration (protrusion of an internal organ through an
incision)
-infection (redness, edema, pain, purulent drainage)
what is the purpose of wound drains - Answer to provide an exit for blood & pus that
accumulate during the inflammation process
how does an active drain work - Answer it is attached to a wound suction device to remove
any accumulated exudate or other material
(ex. Hemovac & Jackson-Pratt)
, how does a passive drain work - Answer it has no suction device, it works by the increased
pressure inside the wound & depends on gravity & capillary action to pull out any fluid buildup
(Penrose)
what do you assess with drainage - Answer color
consistency
odor
amount
what are the advantages of negative pressure wound therapy (wound vac) - Answer -
increase healing rate by 40%
-increases blood flow to wound
-less frequent dressing changes
-improved tissue growth
-draws out fluid
what is negative pressure wound therapy - Answer vacuum assisted closure involves
applying a suction device to a special dressing to institute negative pressure at the site, drawing
the edges together, a mechanical stretch of cells occur which increases cellular proliferation and
tissue growth
a cold compress can be on no longer than____________________________ - Answer 20
minutes
what is the most common place for neuropathic ulcers - Answer metatarsals
what is charcot foot - Answer when the arch collapses and causes an ulcer
what do you assess about a wound - Answer the skin around it for:
edema
erythema
temp
what are types of wound closures - Answer sutures
staples
steri-strips (if wound is small)
