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

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1.  True or False:Repeated trauma to a wound area results in delayed healing or the inability to heal. This is a systemic factor that affects wound healing.
A.
B.
2.  Name one of the scales used to assess the risk of pressure ulcer
3.  Hemovacs and Jackson-Pratt dainage tubes are open or closed drainage systems?
4.  Osteomyelitis is
A.
B.
C.
D.
E.
5.  The skin has ___ layers, in addition to the subcutaneous tissue layer
6.  _____ is a thick, leathery scab or dry crust that is necrotic and must be removed before the stage can be determined accurately.
7.  Peter Griffin is experiencing light pink and blood tinged exudate from a wound. This is what kind of drainage?
A.
B.
C.
D.
E.
8.  Bandages and Binders: A T-binder is used for:
A.
B.
C.
D.
E.
9.  Which type of intention is characterized by intentional wounds with minimal tissue loss, in which the edges are closely approximated?
10.  The skin is the body's ___ line of defense
11.  ____ is a condition caused by ecessive bile pigments in the skin
12.  True or False:Reactive hyperemia is a pressure ulcer.
A.
B.
13.  Meg Griffin is experiencing thick, foul smelling, green exudate from a wound. What kind of drainage is this?
A.
B.
C.
D.
E.
14.  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.
15.  Granulation tissue:
16.  An appropriate nursing diagnosis for a stage ___ pressure ulcer is Impaired skin integrity.
17.  A ____ wound occurs from intentional or unintentional trauma. The skin surface is broken. Examples include incisons and abrasions.
18.  Which of the following is not a form of moist heat?
A.
B.
C.
D.
E.
19.  A T-tube is used for _____ drainage.
20.  A local factor that affects wound healing, noted by disrupting the blood supply to the wound area is known as.
21.  Which of the following is not a form of dry heat?
A.
B.
C.
D.
E.
22.  A wound infection can lead to other complications, including ______, which is the presence of pathogenic organisms in the blood or tissues
23.  True or False:Oxygenation of tissues is decreased in people with anemia.
A.
B.
24.  True or false:The skin is continuous with the mucous membranes, which is made of epithelium.
25.  True or False:Persistent or excessive pressure promotes blood flow to the wound tissue, speeding the healing process.
26.  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.
27.  In the inflammatory phase of wound healing, this type of white blood cell arrive first to ingest bacteria and cellular debris .
A.
B.
C.
D.
E.
28.  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.
29.  Which of the following is not a form of dry cold application?
A.
B.
C.
D.
E.
30.  Which of the following is not a factor affecting skin integrity?
31.  Which of the following does not contribute to pressure ulcer development?
A.
B.
C.
D.
E.
32.  ____ 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.
33.  Which type of intention is defined as having edges that are not well approximated.
34.  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.
35.  Which is a pressure-relieving measures for a stage I pressure ulcer
A.
B.
C.
D.
E.
36.  True or False:One of the characteristics of a stage II pressure ulcer is partial-thickness skin loss, involving only the epdermis
A.
B.
C.
37.  Imagine you are an ER nurse. You're working the night shift on Friday night when you are first introduced to Mr. Griffin. Mr. Griffin has had an accident because he was throwing knives for recreation. Somehow, the patient managed to slice a severely large wound in his arm. The doctors have decided to allow the wound to heal on its own for a few days. Mr. Griffin comes back to the ER several days later (as instructed by the doctors) and the physican decides it is appropriate to suture the wound now. What kind of wound healing has occurred.
A.
B.
C.
D.
E.
38.  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.
39.  The application of heat is not used to treat
A.
B.
C.
D.
E.
40.  Bandages and Binders: The spiral turn is used for
A.
B.
C.
D.
E.
41.  The R in RYB means ____ and is in the _____ stage of healing. (separate answer with a space)
42.  True or False:Healing can occur despite necrotic tissue in the wound.
A.
B.
C.
43.  Which of the following is not true of wounds that are treated by leaving them open to air.
A.
B.
C.
D.
E.
44.  Binders and Bandages: A straight binder is used for
A.
B.
C.
D.
E.
45.  Which of these is true about assessing the appearance of a pressure ulcer.
46.  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.
47.  This type of classification is a wound that is the result of planned invasive therapy or treatment. The would edges are clean.
48.  Which of the following is not true about a stage I pressure ulcer
A.
B.
C.
D.
E.
49.  A pressure ulcer is a:
A.
B.
C.
D.
50.  Which type of wound is characterized by: blunt instrument, overlying skn remains intact, with injury to underlying soft tissue; possible resultant bruising and/or hemotoma.
51.  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.
52.  Which of the following drains allows healing from base of wound
A.
B.
C.
D.
E.
53.  Which of the followng is not a systemic factor affecting wound healing:
54.  Which of the following is a characteristic of the subcutaneous tissue layer
55.  Increased supply of oxygen and nutrients to the area is due to vasodilation which is due to the application of _______.
56.  The most serious postoperative wound complication is a:
A.
B.
C.
D.
E.
57.  Which of the following is synonymous for "pressure ulcer"
A.
B.
C.
D.
58.  Which of the following is not a classification of wounds?
59.  Which structure of the hair lies strictly in the dermis
60.  How many mechanisms contribute to pressure ulcer development?
61.  Cold is not generally applied to
A.
B.
C.
D.
E.
62.  Which is true of fibrin sealants
A.
B.
C.
D.
E.
63.  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.
64.  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.
65.  A collection of infected fluid that has not drained is a
A.
B.
C.
D.
E.
66.  When pressure is releived from an area with ischemia, the body literally floods the area with blood to nourish and remove wastes from the cells. This is called
67.  A type of wound that is characterized by cutting or by a sharp instrument, in which wound endges are in close approximation and aligned is called a _____
68.  Which of the following includes all sites that are at high-risk and likelihood for external pressure related bedsores?
A.
B.
C.
D.
E.
69.  A characteristic of an unintentional wound is:
A.
B.
C.
D.
E.
70.  Which of the following is not a psycholgocal effect of wounds?
A.
B.
C.
D.
E.
71.  Which structure of the hair profects beyond the surface of the skin
72.  During which wound healing phase is collagen that was depositied earlier remodeled.
73.  True or false:Desiccation is the process of drying up. Cells dehydrate and die in a dry environment. This promotes healing.
A.
B.
74.  Granulation tissue, which forms the foundation for scar tissue development, is made in which phase of wound healing? (make sure to include the word "phase" in the answer)
75.  A ____ is a break or disruption in the normal integrity of the skin and tissues.
76.  Which of the following is not true of a stage IV pressure ulcer?
A.
B.
C.
D.
E.
77.  Desiccation is:
78.  What is defined as a plasma and blood component that leaks out into an area that is injured?
79.  Which of the functions of the skin is defned as "water, electrolytes, and nitrogenous wastes are excreted in small amounts of sweat"
80.  Which is not true of a stage II pressure ulcer?
A.
B.
C.
D.
E.
81.  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.
82.  An appropriate nursing dianosis for a stage ______ pressure ulcer is Impaired tissue integrity
83.  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?
84.  Which of the following does not create a higher risk for infection?
A.
B.
C.
D.
E.
85.  Acute inflammation occurs in which of the phases of wound healing
86.  Body temperature is:
A.
B.
C.
D.
E.
87.  Hat is the partial or total separation of wound layers as a result of ecessive stress on wounds that are not healed. In this condition, the muscle is generally intact.
A.
B.
C.
D.
E.
88.  Binders and Bandages: A sling is used for
A.
B.
C.
D.
E.
89.  Which of the following is false about moist cold?
A.
B.
C.
D.
E.
90.  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?
91.  This classification of wounds remains in the inflammatory phase of healing.
92.  Bandages and Binders: Recurrent bandages are used for
93.  The ____ is the top layer. It is made of stratified epithelial cells
94.  Which of the following is not a roller bandage method?
A.
B.
C.
D.
E.
95.  Meg Griffin has sustained a laceration on her leg (her brother Stewie was playing with a machete and she pissed him off). To further punish his sister, Stewies wipes his dirty diaper onto the wound. Soon the wound becomes locally infected, this delays healing because:
96.  Different embryologic origins result in poor adherence between the epidermis and the dermis, createing a loose binding between the layers which seperate easiliy during an inflammatory process. This makes which age group at risk for impaired skin integrity.
97.  Which of the following is not a function of the skin:
98.  _________ is a process of tissue response to injury.
99.  If dehiscence occurs, certain steps should be take. The following steps are in order, however one of them might have a mistake; please distinguish which description of the step is wrong or select "none of the above".  
A.
B.
C.
D.
E.
100.  ________ increases tissue metabolism, reduces blood viscosity, increasees capillary permeability, reduces muscle tension, helps releave pain.
101.  B in RYB stands for ____ or debride. It maybe be indicative of ______, which is usually black but can be brown, gray, or tan. It requires debridement and then the wound is treated as a yellow wound. (separate answers with a space)
102.  True or False:Montgomery straps use ties attached to an adhesive backing to hold dressings in place. They prevent skin irritation and damage due to constant retaping with dressing changes.
A.
B.
103.  A penrose drain
A.
B.
C.
D.
E.
104.  True or False:Friction injury (of a pressure ulcer) resembles an abrasion
A.
B.
105.  This classification of wound usually heals quickly, generally within days to weeks. The wound edges are well approximated and the risk of infection is lessened.
A.
B.
C.
D.
E.
106.  Which of the following does not encourage friction and shearing related pressure ulcers?
A.
B.
C.
D.
E.
107.  Of inspection, palpation, percussion, and auscultation, wound assessment involves inspection (sight and smell) and _____ for appearance, drainage, odour, and pain.
108.  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)
109.  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.
110.  _____ can lead to imparied skin integrity. The damage is related to changes in the pH of skin, over growth of bacteria and infection of the skin, and erosion of the skin from friction on moist skin.
111.  In children younger than ___ years, the skin is thinner and weaker than it is in adults
112.  Hemorrhage may occur from a:
A.
B.
C.
D.
E.
113.  Which is not true about growth factors?
A.
B.
C.
D.
E.
114.  During which phase of wound healing is generalized body response most notably present?
A.
B.
C.
D.
E.
115.  Which of the following influence resistance of skin integrity?
A.
B.
C.
D.
E.
116.  Which of the following is not true of wet-to-dry dressings
A.
B.
C.
D.
E.
117.  The first indication that a pressure ulcer may be developing is:
A.
B.
C.
D.
E.
118.  What is the condition in which the wound completely separates, wich proturion of viscera through the incisional area.
119.  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?
120.  True or False:Wounds that heal by secondary intention scar less than those healed by primary intention.
121.  Which of the following is not true of a Penrose drain?
A.
B.
C.
D.
E.
122.  Which is not true of a stage III pressure ulcer?
A.
B.
C.
D.
E.
123.  Stewie Griffin is experiencing exudate from a wound that appears clear and watery; what type of drainage is this?
A.
B.
C.
D.
E.
124.  Which of the following doesn't affect the health of skin?
125.  True or False:All mucous membranes, except the mouth, are insensitive to temperature.
126.  The dermis does not consists of
A.
B.
C.
D.
E.
127.  Collagen synthesis occurs in which phase of wound healing?
128.  Dr. Hartman has diagnosed Peter Griffin as obese because he has large amounts of subcutaneous and tissue fat. This:
A.
B.
C.
D.
E.
129.  True or False:Maceration is often related to urinary and fecal incontinence.
130.  In this phase of wound healing, new tissue is build to fill wound space, primarily through the action of fibroblasts.
1 comment
131.  Which of the following is true?
A.
B.
C.
D.
E.
132.  The skin is not made up of which of the following:
A.
B.
C.
D.
E.
133.  Which phase of wound healing occurs first?
134.  True or False:Application of cold produces maximum vasoconstriction when the skin reaches 15 degrees C (60 F), then vasodilation occurs.
A.
B.
135.  The skin is also known as the ______
136.  A Jackson-Pratt drain is used after breast removal or in abdominal surgery because it
A.
B.
C.
D.
E.
137.  Who of the following is the most at risk for a pressure ulcer:
A.
B.
C.
D.
E.
138.  There are ____ types of wound healing.
139.  Decreased local relase of pain-producing substances such as histamine, serotonin, and bradykinin, reduced formation of edema and inflammation, and controlled bleeding is due to the application of _____.
140.  Which of the following is not true about external pressure that contribute to pressure ulcer development?
A.
B.
C.
D.
E.
141.  Which of the following is not a wound complicatoin:
142.  Due to a sexscapade gone terribly wrong, Glenn Quagmire's wound now appears moist with yellow stringy tissue. This is:
143.  Lois Griffin is experiencing red drainage from a wound. What kind of exudate is this?
A.
B.
C.
D.
E.
144.  Which of the following is not a risk for pressure ulcer development
A.
B.
C.
D.
E.
145.  A large or open wound, such as a burn or major trauma, left alone to heal is:
A.
B.
C.
D.
E.
146.  Pathologic changes at a pressure ulcer site result from blood vessels collapse, caused by ______, usually from body weight. Necrosis eventually occurs.
147.  The maturation phase of wound healing begins about ____ weeks after the injury, possibly ocntinuing for months or years.
148.  What type of tissue forms the foundation for scar tissue development
149.  What classification of wounds is a result from a blow, force, or strain caused by trauma, such as a fall or car accident.
150.  A characteristic of jaundice is
151.  ____ is local anemia and blanching resulting from poor circulation
152.  The inflammatory cellular phase of wound healing lasts about ___ to ___ days
153.  ______ 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)
154.  True or False:Application of heat produces maximum vasodilation in 5 to 10 minutes; beyond that point tissue congestion and vasoconstriction occurs.
A.
B.
155.  Wound _______ is the directional flow of solution over tissues that is used to clean opon wounds of cellular debris and drainage.
156.  _____ appear in the inflammatory phase, about 24 hours after the appearance of leukocytes.
157.  An open or closed drainage system constists of a drainage tube that is often connected to a electrical suction device?
158.  ______, or wound drainage, is described as serous, sanguineous, serosanguineous, or purulent.
159.  One of the most common skin and tissue disruption is:
A.
B.
C.
D.
E.
160.  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.
161.  Which of the following does not affect the skin as a person ages?
162.  Bandages and Binders: A figure-of-eight turn is often used for:
A.
B.
C.
D.
E.
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