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

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 Nurs 200 - Exam 2 - Chapter 38: Skin Integrity And Wound Care
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1.  Stewie Griffin is experiencing exudate from a wound that appears clear and watery; what type of drainage is this?
A.
B.
C.
D.
E.
2.  A characteristic of an unintentional wound is:
A.
B.
C.
D.
E.
3.  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
4.  ________ increases tissue metabolism, reduces blood viscosity, increasees capillary permeability, reduces muscle tension, helps releave pain.
5.  A T-tube is used for _____ drainage.
6.  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.
7.  Bandages and Binders: The spiral turn is used for
A.
B.
C.
D.
E.
8.  Which of the following is not a roller bandage method?
A.
B.
C.
D.
E.
9.  Meg Griffin is experiencing thick, foul smelling, green exudate from a wound. What kind of drainage is this?
A.
B.
C.
D.
E.
10.  ______ 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)
11.  Lois Griffin is experiencing red drainage from a wound. What kind of exudate is this?
A.
B.
C.
D.
E.
Discuss this Question
12.  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.
13.  Which of the following is not true about a stage I pressure ulcer
A.
B.
C.
D.
E.
14.  A collection of infected fluid that has not drained is a
A.
B.
C.
D.
E.
15.  Cold is not generally applied to
A.
B.
C.
D.
E.
16.  What classification of wounds is a result from a blow, force, or strain caused by trauma, such as a fall or car accident.
17.  True or false:Desiccation is the process of drying up. Cells dehydrate and die in a dry environment. This promotes healing.
A.
B.
Discuss this Question
18.  Which of the following does not contribute to pressure ulcer development?
A.
B.
C.
D.
E.
19.  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)
20.  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.
21.  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.
22.  Which of the following is not true of a Penrose drain?
A.
B.
C.
D.
E.
23.  Which of the following is not true of wet-to-dry dressings
A.
B.
C.
D.
E.
24.  Which is a pressure-relieving measures for a stage I pressure ulcer
A.
B.
C.
D.
E.
25.  Which type of intention is defined as having edges that are not well approximated.
26.  True or False:Application of heat produces maximum vasodilation in 5 to 10 minutes; beyond that point tissue congestion and vasoconstriction occurs.
A.
B.
27.  Which is true of fibrin sealants
A.
B.
C.
D.
E.
28.  Which of the following is synonymous for "pressure ulcer"
A.
B.
C.
D.
29.  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.
30.  Bandages and Binders: A figure-of-eight turn is often used for:
A.
B.
C.
D.
E.
31.  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?
32.  True or False:Friction injury (of a pressure ulcer) resembles an abrasion
A.
B.
33.  Peter Griffin is experiencing light pink and blood tinged exudate from a wound. This is what kind of drainage?
A.
B.
C.
D.
E.
34.  Which of the following includes all sites that are at high-risk and likelihood for external pressure related bedsores?
A.
B.
C.
D.
E.
35.  Body temperature is:
A.
B.
C.
D.
E.
36.  The skin has ___ layers, in addition to the subcutaneous tissue layer
37.  A wound infection can lead to other complications, including ______, which is the presence of pathogenic organisms in the blood or tissues
38.  Increased supply of oxygen and nutrients to the area is due to vasodilation which is due to the application of _______.
39.  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.
40.  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.
41.  Wound _______ is the directional flow of solution over tissues that is used to clean opon wounds of cellular debris and drainage.
42.  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.
43.  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.
44.  There are ____ types of wound healing.
45.  Which of the following is not a form of dry heat?
A.
B.
C.
D.
E.
46.  How many mechanisms contribute to pressure ulcer development?
47.  An open or closed drainage system constists of a drainage tube that is often connected to a electrical suction device?
48.  True or False:Oxygenation of tissues is decreased in people with anemia.
A.
B.
49.  An appropriate nursing diagnosis for a stage ___ pressure ulcer is Impaired skin integrity.
50.  Bandages and Binders: A T-binder is used for:
A.
B.
C.
D.
E.
51.  True or False:Healing can occur despite necrotic tissue in the wound.
A.
B.
C.
52.  An appropriate nursing dianosis for a stage ______ pressure ulcer is Impaired tissue integrity
53.  Binders and Bandages: A sling is used for
A.
B.
C.
D.
E.
54.  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.
55.  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.
56.  The application of heat is not used to treat
A.
B.
C.
D.
E.
57.  True or False:Reactive hyperemia is a pressure ulcer.
A.
B.
58.  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)
59.  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.
60.  One of the most common skin and tissue disruption is:
A.
B.
C.
D.
E.
61.  The first indication that a pressure ulcer may be developing is:
A.
B.
C.
D.
E.
Discuss this Question
62.  Dr. Hartman has diagnosed Peter Griffin as obese because he has large amounts of subcutaneous and tissue fat. This:
A.
B.
C.
D.
E.
63.  Which is not true of a stage III pressure ulcer?
A.
B.
C.
D.
E.
64.  Binders and Bandages: A straight binder is used for
A.
B.
C.
D.
E.
65.  Which of the following influence resistance of skin integrity?
A.
B.
C.
D.
E.
66.  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.
67.  The skin is also known as the ______
68.  Which of the following is not a risk for pressure ulcer development
A.
B.
C.
D.
E.
69.  A large or open wound, such as a burn or major trauma, left alone to heal is:
A.
B.
C.
D.
E.
70.  Acute inflammation occurs in which of the phases of wound healing
71.  Who of the following is the most at risk for a pressure ulcer:
A.
B.
C.
D.
E.
72.  Which of the following is not true about external pressure that contribute to pressure ulcer development?
A.
B.
C.
D.
E.
73.  Which of the following is not a form of moist heat?
A.
B.
C.
D.
E.
74.  A ____ is a break or disruption in the normal integrity of the skin and tissues.
75.  What type of tissue forms the foundation for scar tissue development
76.  During which phase of wound healing is generalized body response most notably present?
A.
B.
C.
D.
E.
77.  Which phase of wound healing occurs first?
78.  Which of the following does not encourage friction and shearing related pressure ulcers?
A.
B.
C.
D.
E.
79.  The R in RYB means ____ and is in the _____ stage of healing. (separate answer with a space)
80.  A penrose drain
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.  Which structure of the hair profects beyond the surface of the skin
83.  A pressure ulcer is a:
A.
B.
C.
D.
84.  Which of the following is not a psycholgocal effect of wounds?
A.
B.
C.
D.
E.
85.  Which of the functions of the skin is defned as "water, electrolytes, and nitrogenous wastes are excreted in small amounts of sweat"
86.  Which of the following is not true of a stage IV pressure ulcer?
A.
B.
C.
D.
E.
87.  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.
88.  Which of the following is not a form of dry cold application?
A.
B.
C.
D.
E.
89.  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.
90.  The most serious postoperative wound complication is a:
A.
B.
C.
D.
E.
Discuss this Question
91.  True or False:Application of cold produces maximum vasoconstriction when the skin reaches 15 degrees C (60 F), then vasodilation occurs.
A.
B.
92.  Osteomyelitis is
A.
B.
C.
D.
E.
93.  Which is not true about growth factors?
A.
B.
C.
D.
E.
94.  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)
95.  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.
96.  Pathologic changes at a pressure ulcer site result from blood vessels collapse, caused by ______, usually from body weight. Necrosis eventually occurs.
97.  Which type of intention is characterized by intentional wounds with minimal tissue loss, in which the edges are closely approximated?
98.  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.
99.  Which of the following drains allows healing from base of wound
A.
B.
C.
D.
E.
100.  _____ is a thick, leathery scab or dry crust that is necrotic and must be removed before the stage can be determined accurately.
101.  Hemovacs and Jackson-Pratt dainage tubes are open or closed drainage systems?
102.  ____ is local anemia and blanching resulting from poor circulation
103.  Which of the following is not true of wounds that are treated by leaving them open to air.
A.
B.
C.
D.
E.
104.  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.
105.  Which of the following does not create a higher risk for infection?
A.
B.
C.
D.
E.
106.  The dermis does not consists of
A.
B.
C.
D.
E.
Discuss this Question
107.  This classification of wounds remains in the inflammatory phase of healing.
108.  Which is not true of a stage II pressure ulcer?
A.
B.
C.
D.
E.
Discuss this Question
109.  A Jackson-Pratt drain is used after breast removal or in abdominal surgery because it
A.
B.
C.
D.
E.
110.  This type of classification is a wound that is the result of planned invasive therapy or treatment. The would edges are clean.
111.  Which of the following is false about moist cold?
A.
B.
C.
D.
E.
112.  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.
113.  Hemorrhage may occur from a:
A.
B.
C.
D.
E.
114.  ______, or wound drainage, is described as serous, sanguineous, serosanguineous, or purulent.
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