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

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1.  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.
2.  True or False:Reactive hyperemia is a pressure ulcer.
A.
B.
3.  A ____ is a break or disruption in the normal integrity of the skin and tissues.
4.  There are ____ types of wound healing.
5.  Which of the following includes all sites that are at high-risk and likelihood for external pressure related bedsores?
A.
B.
C.
D.
E.
6.  Which of the following does not encourage friction and shearing related pressure ulcers?
A.
B.
C.
D.
E.
7.  Which of the following does not create a higher risk for infection?
A.
B.
C.
D.
E.
8.  Bandages and Binders: The spiral turn is used for
A.
B.
C.
D.
E.
9.  Which of the following is not a risk for pressure ulcer development
A.
B.
C.
D.
E.
10.  Wound _______ is the directional flow of solution over tissues that is used to clean opon wounds of cellular debris and drainage.
11.  During which phase of wound healing is generalized body response most notably present?
A.
B.
C.
D.
E.
12.  Which is not true of a stage III pressure ulcer?
A.
B.
C.
D.
E.
13.  The maturation phase of wound healing begins about ____ weeks after the injury, possibly ocntinuing for months or years.
14.  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.
15.  Pathologic changes at a pressure ulcer site result from blood vessels collapse, caused by ______, usually from body weight. Necrosis eventually occurs.
16.  The inflammatory cellular phase of wound healing lasts about ___ to ___ days
17.  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:
18.  Which of the following is not a form of dry heat?
A.
B.
C.
D.
E.
19.  This classification of wounds remains in the inflammatory phase of healing.
20.  Which of the following is not a wound complicatoin:
21.  The skin is not made up of which of the following:
A.
B.
C.
D.
E.
22.  A characteristic of an unintentional wound is:
A.
B.
C.
D.
E.
23.  What is the condition in which the wound completely separates, wich proturion of viscera through the incisional area.
24.  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?
25.  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.
26.  The R in RYB means ____ and is in the _____ stage of healing. (separate answer with a space)
27.  During which wound healing phase is collagen that was depositied earlier remodeled.
28.  A T-tube is used for _____ drainage.
29.  Which of the following is not a psycholgocal effect of wounds?
A.
B.
C.
D.
E.
30.  How many mechanisms contribute to pressure ulcer development?
31.  The skin is also known as the ______
32.  Desiccation is:
33.  Which of the following is not true about a stage I pressure ulcer
A.
B.
C.
D.
E.
34.  Bandages and Binders: A T-binder is used for:
A.
B.
C.
D.
E.
35.  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.
36.  Which of the following is not a function of the skin:
37.  Binders and Bandages: A sling is used for
A.
B.
C.
D.
E.
38.  Meg Griffin is experiencing thick, foul smelling, green exudate from a wound. What kind of drainage is this?
A.
B.
C.
D.
E.
39.  Which of the following is false about moist cold?
A.
B.
C.
D.
E.
40.  Which structure of the hair profects beyond the surface of the skin
41.  ________ increases tissue metabolism, reduces blood viscosity, increasees capillary permeability, reduces muscle tension, helps releave pain.
42.  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.
43.  One of the most common skin and tissue disruption is:
A.
B.
C.
D.
E.
44.  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.
45.  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?
46.  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.
47.  A penrose drain
A.
B.
C.
D.
E.
48.  An appropriate nursing dianosis for a stage ______ pressure ulcer is Impaired tissue integrity
49.  _____ is a thick, leathery scab or dry crust that is necrotic and must be removed before the stage can be determined accurately.
50.  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.
51.  True or False:Application of cold produces maximum vasoconstriction when the skin reaches 15 degrees C (60 F), then vasodilation occurs.
A.
B.
52.  True or false:Desiccation is the process of drying up. Cells dehydrate and die in a dry environment. This promotes healing.
A.
B.
53.  In children younger than ___ years, the skin is thinner and weaker than it is in adults
54.  This type of classification is a wound that is the result of planned invasive therapy or treatment. The would edges are clean.
55.  True or false:The skin is continuous with the mucous membranes, which is made of epithelium.
56.  The skin is the body's ___ line of defense
57.  Which of the following is not true of wounds that are treated by leaving them open to air.
A.
B.
C.
D.
E.
58.  Collagen synthesis occurs in which phase of wound healing?
59.  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 _____.
60.  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)
61.  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.
62.  True or False:Friction injury (of a pressure ulcer) resembles an abrasion
A.
B.
63.  An appropriate nursing diagnosis for a stage ___ pressure ulcer is Impaired skin integrity.
64.  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.
65.  Increased supply of oxygen and nutrients to the area is due to vasodilation which is due to the application of _______.
66.  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.
67.  Which of the following is not a form of moist heat?
A.
B.
C.
D.
E.
68.  Which of the following drains allows healing from base of wound
A.
B.
C.
D.
E.
69.  Due to a sexscapade gone terribly wrong, Glenn Quagmire's wound now appears moist with yellow stringy tissue. This is:
70.  ______, or wound drainage, is described as serous, sanguineous, serosanguineous, or purulent.
71.  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.
72.  Which of the following is synonymous for "pressure ulcer"
A.
B.
C.
D.
73.  Acute inflammation occurs in which of the phases of wound healing
74.  Which of the following is not a classification of wounds?
75.  Which phase of wound healing occurs first?
76.  Which type of intention is defined as having edges that are not well approximated.
77.  Which of the functions of the skin is defned as "water, electrolytes, and nitrogenous wastes are excreted in small amounts of sweat"
78.  Stewie Griffin is experiencing exudate from a wound that appears clear and watery; what type of drainage is this?
A.
B.
C.
D.
E.
79.  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 _____
80.  Peter Griffin is experiencing light pink and blood tinged exudate from a wound. This is what kind of drainage?
A.
B.
C.
D.
E.
81.  What is defined as a plasma and blood component that leaks out into an area that is injured?
82.  Name one of the scales used to assess the risk of pressure ulcer
83.  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.
84.  Which of the following does not contribute to pressure ulcer development?
A.
B.
C.
D.
E.
85.  Which of the following does not affect the skin as a person ages?
86.  Which structure of the hair lies strictly in the dermis
87.  Binders and Bandages: A straight binder is used for
A.
B.
C.
D.
E.
88.  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.
89.  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.
90.  _____ 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.
91.  Bandages and Binders: Recurrent bandages are used for
92.  True or False:Application of heat produces maximum vasodilation in 5 to 10 minutes; beyond that point tissue congestion and vasoconstriction occurs.
A.
B.
93.  Which of the following is a characteristic of the subcutaneous tissue layer
94.  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
95.  The first indication that a pressure ulcer may be developing is:
A.
B.
C.
D.
E.
96.  A large or open wound, such as a burn or major trauma, left alone to heal is:
A.
B.
C.
D.
E.
97.  Which of the followng is not a systemic factor affecting wound healing:
98.  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.
99.  Which is true of fibrin sealants
A.
B.
C.
D.
E.
100.  A local factor that affects wound healing, noted by disrupting the blood supply to the wound area is known as.
101.  What type of tissue forms the foundation for scar tissue development
102.  Which of the following is true?
A.
B.
C.
D.
E.
103.  Which of the following is not a form of dry cold application?
A.
B.
C.
D.
E.
104.  _________ is a process of tissue response to injury.
105.  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.
106.  A collection of infected fluid that has not drained is a
A.
B.
C.
D.
E.
107.  ____ is local anemia and blanching resulting from poor circulation
108.  Which of the following doesn't affect the health of skin?
109.  Hemorrhage may occur from a:
A.
B.
C.
D.
E.
110.  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?
111.  True or False:Oxygenation of tissues is decreased in people with anemia.
A.
B.
112.  Which is not true about growth factors?
A.
B.
C.
D.
E.
113.  Of inspection, palpation, percussion, and auscultation, wound assessment involves inspection (sight and smell) and _____ for appearance, drainage, odour, and pain.
114.  Cold is not generally applied to
A.
B.
C.
D.
E.
115.  A pressure ulcer is a:
A.
B.
C.
D.
116.  Who of the following is the most at risk for a pressure ulcer:
A.
B.
C.
D.
E.
117.  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.
118.  A wound infection can lead to other complications, including ______, which is the presence of pathogenic organisms in the blood or tissues
119.  True or False:Wounds that heal by secondary intention scar less than those healed by primary intention.
120.  A ____ wound occurs from intentional or unintentional trauma. The skin surface is broken. Examples include incisons and abrasions.
121.  ______ 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)
122.  ____ 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.
123.  Which of the following is not a roller bandage method?
A.
B.
C.
D.
E.
124.  Which of the following is not true of wet-to-dry dressings
A.
B.
C.
D.
E.
125.  Which is not true of a stage II pressure ulcer?
A.
B.
C.
D.
E.
126.  Osteomyelitis is
A.
B.
C.
D.
E.
127.  _____ appear in the inflammatory phase, about 24 hours after the appearance of leukocytes.
128.  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.
129.  True or False:All mucous membranes, except the mouth, are insensitive to temperature.
130.  Which is a pressure-relieving measures for a stage I pressure ulcer
A.
B.
C.
D.
E.
131.  A Jackson-Pratt drain is used after breast removal or in abdominal surgery because it
A.
B.
C.
D.
E.
132.  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.
133.  A characteristic of jaundice is
134.  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)
135.  In this phase of wound healing, new tissue is build to fill wound space, primarily through the action of fibroblasts.
1 comment
136.  The dermis does not consists of
A.
B.
C.
D.
E.
137.  What classification of wounds is a result from a blow, force, or strain caused by trauma, such as a fall or car accident.
138.  True or False:Persistent or excessive pressure promotes blood flow to the wound tissue, speeding the healing process.
139.  True or False:Healing can occur despite necrotic tissue in the wound.
A.
B.
C.
140.  Granulation tissue:
141.  The skin has ___ layers, in addition to the subcutaneous tissue layer
142.  Body temperature is:
A.
B.
C.
D.
E.
143.  True or False:Maceration is often related to urinary and fecal incontinence.
144.  Bandages and Binders: A figure-of-eight turn is often used for:
A.
B.
C.
D.
E.
145.  Which of these is true about assessing the appearance of a pressure ulcer.
146.  Which of the following influence resistance of skin integrity?
A.
B.
C.
D.
E.
147.  Which of the following is not true of a stage IV pressure ulcer?
A.
B.
C.
D.
E.
148.  The ____ is the top layer. It is made of stratified epithelial cells
149.  Which of the following is not true about external pressure that contribute to pressure ulcer development?
A.
B.
C.
D.
E.
150.  The application of heat is not used to treat
A.
B.
C.
D.
E.
151.  Lois Griffin is experiencing red drainage from a wound. What kind of exudate is this?
A.
B.
C.
D.
E.
152.  Which type of intention is characterized by intentional wounds with minimal tissue loss, in which the edges are closely approximated?
153.  Hemovacs and Jackson-Pratt dainage tubes are open or closed drainage systems?
154.  Dr. Hartman has diagnosed Peter Griffin as obese because he has large amounts of subcutaneous and tissue fat. This:
A.
B.
C.
D.
E.
155.  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)
156.  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.
157.  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.
158.  The most serious postoperative wound complication is a:
A.
B.
C.
D.
E.
159.  Which of the following is not true of a Penrose drain?
A.
B.
C.
D.
E.
160.  ____ is a condition caused by ecessive bile pigments in the skin
161.  Which of the following is not a factor affecting skin integrity?
162.  An open or closed drainage system constists of a drainage tube that is often connected to a electrical suction device?
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