Nurs 200 - Exam 2 - Chapter 38: Skin Integrity And Wound Care

162 Questions  I  By Lailaa
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1.  Which of the following does not affect the skin as a person ages?
2.  Which is not true of a stage III pressure ulcer?
A.
B.
C.
D.
E.
3.  A collection of infected fluid that has not drained is a
A.
B.
C.
D.
E.
4.  Bandages and Binders: Recurrent bandages are used for
5.  The first indication that a pressure ulcer may be developing is:
A.
B.
C.
D.
E.
6.  Which phase of wound healing occurs first?
7.  The R in RYB means ____ and is in the _____ stage of healing. (separate answer with a space)
8.  A ____ is an abnormal passage from an internal organ to the outside of the body or from one internal organ to another. It may be purosefully created; however it is often the result of infection that has developed into an abscess.
9.  Which structure of the hair profects beyond the surface of the skin
10.  Hemorrhage may occur from a:
A.
B.
C.
D.
E.
11.  Which of the following is synonymous for "pressure ulcer"
A.
B.
C.
D.
12.  A large or open wound, such as a burn or major trauma, left alone to heal is:
A.
B.
C.
D.
E.
13.  Who of the following is the most at risk for a pressure ulcer:
A.
B.
C.
D.
E.
14.  Osteomyelitis is
A.
B.
C.
D.
E.
15.  _____ is a thick, leathery scab or dry crust that is necrotic and must be removed before the stage can be determined accurately.
16.  Bandages and Binders: A T-binder is used for:
A.
B.
C.
D.
E.
17.  One of the most common skin and tissue disruption is:
A.
B.
C.
D.
E.
18.  An appropriate nursing dianosis for a stage ______ pressure ulcer is Impaired tissue integrity
19.  What is the condition in which the wound completely separates, wich proturion of viscera through the incisional area.
20.  Herbert is 82 years old, dehydrated, and malnurished. He also suffers from diabetes and urinary incontinence. Moreover, mayor Adam West has stolen his walker, so he spends a lot of time sitting on his porch chair, lusting after Chris Griffin. These are high risk factors for _______ development.
21.  The skin is not made up of which of the following:
A.
B.
C.
D.
E.
22.  Which of the following is not a roller bandage method?
A.
B.
C.
D.
E.
23.  The application of heat is not used to treat
A.
B.
C.
D.
E.
24.  The ____ is the top layer. It is made of stratified epithelial cells
25.  Increased supply of oxygen and nutrients to the area is due to vasodilation which is due to the application of _______.
26.  The Y in RYB stands for ______; it may be indicative of  exudate or slough and requires wound ____. It is often accompanied by purulent drainage. (separate answers with a space)
27.  Due to a sexscapade gone terribly wrong, Glenn Quagmire's wound now appears moist with yellow stringy tissue. This is:
28.  Stewie Griffin is experiencing exudate from a wound that appears clear and watery; what type of drainage is this?
A.
B.
C.
D.
E.
29.  Which structure of the hair lies strictly in the dermis
30.  A T-tube is used for _____ drainage.
31.  Which is not true of a stage II pressure ulcer?
A.
B.
C.
D.
E.
32.  Chris Griffin is riding his bike about a mile away from home. He makes a sharp turn at a fast speed and loses control of the bicycle. He falls down and skins his knee against the gravel. The wound is not deep, and most of the skin is still present. This is what type of wound?
33.  Meg Griffin is experiencing thick, foul smelling, green exudate from a wound. What kind of drainage is this?
A.
B.
C.
D.
E.
34.  ____ is local anemia and blanching resulting from poor circulation
35.  True or False:Application of cold produces maximum vasoconstriction when the skin reaches 15 degrees C (60 F), then vasodilation occurs.
A.
B.
36.  The maturation phase of wound healing begins about ____ weeks after the injury, possibly ocntinuing for months or years.
37.  This type of classification is a wound that is the result of planned invasive therapy or treatment. The would edges are clean.
38.  Which type of intention is characterized by intentional wounds with minimal tissue loss, in which the edges are closely approximated?
39.  True or False:If a dehiscence and evisceration of an abdominal incision occurs, one should leave the patient, rush to the nurses' station, and immediately contact the doctor.
A.
B.
40.  Bandages and Binders: A figure-of-eight turn is often used for:
A.
B.
C.
D.
E.
41.  ________ increases tissue metabolism, reduces blood viscosity, increasees capillary permeability, reduces muscle tension, helps releave pain.
42.  Acute inflammation occurs in which of the phases of wound healing
43.  Which of these is true about assessing the appearance of a pressure ulcer.
44.  True or False:Reactive hyperemia is a pressure ulcer.
A.
B.
45.  ____ is a type of wound in which there is tearing of skin and tissue with blunt or irregular instruments; tissue is not aligned, often with loose flaps of skin and tissue.
46.  True or False:All mucous membranes, except the mouth, are insensitive to temperature.
47.  Cleaveland Brown has been injured at the hands of his ex-wife Loretta brown. While in the hospital he has developed a wound with a localized area of tissue necrosis. He has developed a:
A.
B.
C.
D.
E.
48.  Which of the following does not encourage friction and shearing related pressure ulcers?
A.
B.
C.
D.
E.
49.  Pathologic changes at a pressure ulcer site result from blood vessels collapse, caused by ______, usually from body weight. Necrosis eventually occurs.
50.  Desiccation is:
51.  Stewie Griffin is playing with Rupert outside of his home. All of a sudden, a bee lands on his leg and stings him. Stewie begins crying and screaming obscenities; his mother, Lois, comes to see what is wrong. Upon inspection of the wound, she sees that the stinger is still lodged in his skin. What kind of wound is this?
52.  During which phase of wound healing is generalized body response most notably present?
A.
B.
C.
D.
E.
53.  Name one of the scales used to assess the risk of pressure ulcer
54.  Which is not true about growth factors?
A.
B.
C.
D.
E.
55.  Which of the following is not true about a stage I pressure ulcer
A.
B.
C.
D.
E.
56.  Cold is not generally applied to
A.
B.
C.
D.
E.
57.  The systemic effects of extensive, prolonged heat, which leads to increasing the blood flow to a large area of the body while decreasing it to another part of the body is
A.
B.
C.
D.
E.
58.  In this phase of wound healing, new tissue is build to fill wound space, primarily through the action of fibroblasts.
1 comment
59.  A characteristic of jaundice is
60.  Binders and Bandages: A straight binder is used for
A.
B.
C.
D.
E.
61.  True or False: When determining tunneling of a pressure ulcer, one must use an applicator to determine the deepest point. The nurse should assess the depth of tunneling in a clockwise method; the patient's feet represent 12 o'clock
A.
B.
C.
62.  Of inspection, palpation, percussion, and auscultation, wound assessment involves inspection (sight and smell) and _____ for appearance, drainage, odour, and pain.
63.  True or False:Oxygenation of tissues is decreased in people with anemia.
A.
B.
64.  Far, far away, in a foreign country, Joe Swanson has been caught as a prisoner of war. He is sitting alone in his cell. The militants of this country use a unique method of torture against their prisoners - they peel the skin off the captive. What type of wound is this?
65.  Which of the following is not true of wounds that are treated by leaving them open to air.
A.
B.
C.
D.
E.
66.  What classification of wounds is a result from a blow, force, or strain caused by trauma, such as a fall or car accident.
67.  Which of the following is not true of wet-to-dry dressings
A.
B.
C.
D.
E.
68.  True or False:Maceration is often related to urinary and fecal incontinence.
69.  Which of the following is true?
A.
B.
C.
D.
E.
70.  True or false:The skin is continuous with the mucous membranes, which is made of epithelium.
71.  A pressure ulcer is a:
A.
B.
C.
D.
72.  A wound infection can lead to other complications, including ______, which is the presence of pathogenic organisms in the blood or tissues
73.  Peter Griffin is experiencing light pink and blood tinged exudate from a wound. This is what kind of drainage?
A.
B.
C.
D.
E.
74.  Which of the following does not create a higher risk for infection?
A.
B.
C.
D.
E.
75.  Which of the following is not a form of dry cold application?
A.
B.
C.
D.
E.
76.  Drains may be inserted in or near a wound to ____ drainage, thereby reducing the risk of _____ formation and promoting wound healing.
A.
B.
C.
D.
77.  Which of the following includes all sites that are at high-risk and likelihood for external pressure related bedsores?
A.
B.
C.
D.
E.
78.  Dr. Hartman has diagnosed Peter Griffin as obese because he has large amounts of subcutaneous and tissue fat. This:
A.
B.
C.
D.
E.
79.  True or False:Your body adapts to heat and cold over time. The response is strong at the beginning because heat and cold skin receptors are strongly stimulated by sudden changes in temperature; after that the response decreases more slowly for the next 30 minutes, as the receptors adapt to the temperature. Since your body adapts, it is important to teach patients that they should increase temperature or lengthen the time of application.
A.
B.
80.  The skin is the body's ___ line of defense
81.  True or False:In wounds that heal by primary intention, epidermal cells seal the wound within 24 to 28 hours and the granulation tissue is visible.
A.
B.
82.  ____ is a condition caused by ecessive bile pigments in the skin
83.  ______, or wound drainage, is described as serous, sanguineous, serosanguineous, or purulent.
84.  During which wound healing phase is collagen that was depositied earlier remodeled.
85.  Which is true of fibrin sealants
A.
B.
C.
D.
E.
86.  Which of the following is not true about external pressure that contribute to pressure ulcer development?
A.
B.
C.
D.
E.
87.  The skin has ___ layers, in addition to the subcutaneous tissue layer
88.  Which of the following is not a wound complicatoin:
89.  An appropriate nursing diagnosis for a stage ___ pressure ulcer is Impaired skin integrity.
90.  The dermis does not consists of
A.
B.
C.
D.
E.
91.  Which is a pressure-relieving measures for a stage I pressure ulcer
A.
B.
C.
D.
E.
92.  In which phase do blood vessels constrict to allow blood clotting and then dilate to increase capillary permeability; this allows plasma and blood components to leak out into the area that is injured 
A.
B.
C.
D.
E.
93.  Which of the following influence resistance of skin integrity?
A.
B.
C.
D.
E.
94.  ______ at a wound site interferes with the blood supply to the area, resulting in an inadequate supply of oxygen and nutrients to the tissue. It is a local factor that affects wound healing. (2 possibe answers are correct)
95.  Which of the following doesn't affect the health of skin?
96.  _____ appear in the inflammatory phase, about 24 hours after the appearance of leukocytes.
97.  Which of the following drains allows healing from base of wound
A.
B.
C.
D.
E.
98.  A ____ wound occurs from intentional or unintentional trauma. The skin surface is broken. Examples include incisons and abrasions.
99.  Hemovacs and Jackson-Pratt dainage tubes are open or closed drainage systems?
100.  What local factor (that affects wound healing) requires large amounts of energy be spent by the immune system to fight the invaders, leaving little or no reserves to attend to the attend to the job of repair and healing.
A.
B.
C.
D.
E.
101.  Body temperature is:
A.
B.
C.
D.
E.
102.  Which of the following is not true of a stage IV pressure ulcer?
A.
B.
C.
D.
E.
103.  Lois Griffin has just had a heart transplant. The doctor made an incision into the chest, performed the surgery, and sutured the incision. This is:
A.
B.
C.
D.
E.
104.