Healing Horizons: Skin Integrity And Wound care Quiz

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Healing Horizons: Skin Integrity And Wound care Quiz - Quiz

Are you preparing for the nursing examination? What do you know about skin integrity and wound care? Here is a skin integrity and wound care quiz for you. As a nursing expert, one must understand how to deal with a wound patient. Wounds are vulnerable and dealing with their needs to be given a lot of attention. Here are questions to test you and make you more aware of skin integrity and the process of wound care. All the best!


Questions and Answers
  • 1. 

    The skin is also known as the ______

    Explanation
    The skin is commonly referred to as the integument, integumentary, or integumentary system. These terms all describe the same thing, which is the external covering of the body that protects it from the environment. The integumentary system includes not only the skin but also the hair, nails, and various glands.

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  • 2. 

    The skin has ___ layers, in addition to the subcutaneous tissue layer

    Explanation
    The skin is composed of two main layers, the epidermis and the dermis. The epidermis is the outermost layer of the skin, providing protection and preventing water loss. The dermis is located beneath the epidermis and contains various structures such as blood vessels, hair follicles, and sweat glands. These two layers work together to maintain the integrity and function of the skin. The subcutaneous tissue layer, also known as the hypodermis, is located beneath the dermis and serves as a layer of insulation and padding for the body.

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  • 3. 

    The dermis does not consist of

    • A.

      Connective tissue

    • B.

      Nerves

    • C.

      Hair

    • D.

      Blood vessels

    • E.

      None of the above

    Correct Answer
    E. None of the above
    Explanation
    The dermis is the middle layer of the skin, composed mainly of connective tissue that provides strength and flexibility. It contains nerves that transmit sensory information, allowing us to feel touch, pain, and temperature. The dermis also houses hair follicles, which are responsible for hair growth. Additionally, it is rich in blood vessels that supply nutrients and oxygen to the skin. Therefore, all the options mentioned (connective tissue, nerves, hair, and blood vessels) are present in the dermis, making the correct answer "None of the above".

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  • 4. 

    Which of the functions of the skin is defned as "water, electrolytes, and nitrogenous wastes are excreted in small amounts of sweat"

    Correct Answer
    elimination
    Explanation
    Elimination refers to the process of excreting waste products from the body. In this context, the function of the skin as elimination is described as the excretion of water, electrolytes, and nitrogenous wastes through sweat. Sweat glands in the skin help in regulating body temperature by producing sweat, which contains these waste products. This process aids in maintaining the balance of electrolytes and removing toxins from the body.

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  • 5. 

    Which of the following influence resistance of skin integrity?

    • A.

      Age

    • B.

      Amount of underlying tissue

    • C.

      Illness

    • D.

      All of the above

    • E.

      None of the above

    Correct Answer
    D. All of the above
    Explanation
    All of the factors mentioned - age, amount of underlying tissue, and illness - can influence the resistance of skin integrity. Age can affect the elasticity and thickness of the skin, making it more prone to damage. The amount of underlying tissue can provide support and protection to the skin, affecting its ability to resist damage. Illnesses can weaken the immune system and impair the body's ability to heal, making the skin more susceptible to breakdown. Therefore, all of these factors can play a role in influencing the resistance of skin integrity.

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  • 6. 

    Which structure of the hair profects beyond the surface of the skin

    Correct Answer
    shaft
    hair shaft
    Explanation
    The hair shaft is the correct answer because it is the part of the hair that projects beyond the surface of the skin. The hair shaft is the visible part of the hair that we see and it is composed of dead cells that have been pushed up from the hair follicle. The shaft is responsible for giving the hair its length and texture.

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  • 7. 

    A ____ is a break or disruption in the normal integrity of the skin and tissues.

    Correct Answer
    wound
    Explanation
    A wound refers to a break or disruption in the normal integrity of the skin and tissues. It can be caused by various factors such as cuts, abrasions, punctures, or burns. Wounds can vary in severity, ranging from minor cuts that heal quickly to deep lacerations that require medical attention. Regardless of the cause or severity, all wounds involve damage to the skin and underlying tissues, which can lead to pain, bleeding, and potential infection if not properly treated and cared for.

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  • 8. 

    This type of classification is a wound that is the result of planned invasive therapy or treatment. The would edges are clean.

    Correct Answer
    intentional
    intentional wound
    Explanation
    This answer is correct because the question describes a type of wound that is the result of planned invasive therapy or treatment, and the wound edges are clean. This indicates that the wound was intentionally created during a medical procedure or treatment. Therefore, the correct answer is intentional or intentional wound.

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  • 9. 

    A characteristic of an unintentional wound is:

    • A.

      Accidental

    • B.

      High risk for infection

    • C.

      Clean edges

    • D.

      A and C

    • E.

      All of the above

    Correct Answer
    D. A and C
    Explanation
    An unintentional wound is one that occurs accidentally, such as from a fall or a sharp object. These wounds are not deliberately inflicted. Clean edges refer to wounds that have smooth and well-defined boundaries, indicating a clean cut or tear. Therefore, both the options A and C are characteristics of unintentional wounds. High risk for infection is not specific to unintentional wounds and can apply to any type of wound.

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  • 10. 

    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?

    Correct Answer
    avulsion
    Explanation
    The type of wound described in the question is an avulsion. Avulsion refers to the tearing or separation of skin or tissue from the body. In this case, the militants are peeling the skin off the captive, which involves forcefully removing layers of skin from the body. This results in a severe and traumatic injury, causing significant damage and pain to the victim.

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  • 11. 

    What classification of wounds is a result from a blow, force, or strain caused by trauma, such as a fall or car accident.

    Correct Answer
    closed wound, closed
    Explanation
    A closed wound is a classification of wounds that occurs when there is no break in the skin. It is caused by a blow, force, or strain from trauma, such as a fall or car accident. In this type of wound, the skin remains intact, but there may be damage to underlying tissues, muscles, or organs. The term "closed" refers to the fact that there is no open wound or visible break in the skin.

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  • 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.

      Abrasion wound

    • B.

      Acute wound

    • C.

      Chronic wound

    • D.

      Unintentional wound

    • E.

      None of the above

    Correct Answer
    B. Acute wound
    Explanation
    An acute wound is the correct answer because it is characterized by wounds that usually heal quickly within days to weeks. The wound edges are well approximated, meaning they are close together, and the risk of infection is lessened. Acute wounds are typically caused by a traumatic event, such as a cut or a surgical incision, and they have a predictable healing process.

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  • 13. 

    This classification of wounds remains in the inflammatory phase of healing.

    Correct Answer
    chronic, chronic wound
    Explanation
    The given correct answer is "chronic, chronic wound." This classification of wounds suggests that the wound is in the inflammatory phase of healing. Chronic wounds are those that do not heal within the expected timeframe and often remain in the inflammatory phase for an extended period. This can be due to various factors such as poor blood supply, underlying health conditions, or repeated trauma to the wound site. Therefore, the presence of chronic wounds indicates that the wound is still in the inflammatory phase of healing.

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  • 14. 

    There are ____ types of wound healing.

    Correct Answer
    3
    three
    Explanation
    The correct answer is 3, three. The question asks for the number of types of wound healing. Wound healing can be categorized into three main types: primary intention, secondary intention, and tertiary intention. Primary intention occurs when the wound edges are brought together and closed with sutures, staples, or adhesive. Secondary intention refers to the healing process where the wound is left open to heal from the bottom up, and it usually occurs in larger wounds with significant tissue loss. Tertiary intention, also known as delayed primary closure, combines elements of both primary and secondary intention and involves initially leaving the wound open to allow for drainage and then closing it later.

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  • 15. 

    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.

      Primary intention

    • B.

      Delayed primary intention

    • C.

      Secondary intention

    • D.

      Tertiary intention

    • E.

      A and B

    Correct Answer
    A. Primary intention
    Explanation
    Primary intention refers to the healing process of a surgical wound where the edges of the incision are brought together and closed with sutures or staples, allowing for a faster and more organized healing process. In this case, Lois Griffin's incision was made, the surgery was performed, and then the incision was sutured, indicating that the wound was closed immediately after the surgery, following the primary intention healing process.

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  • 16. 

    Which type of intention is characterized by intentional wounds with minimal tissue loss, in which the edges are closely approximated?

    Correct Answer
    primary
    primary intention
    Explanation
    Primary intention refers to a type of intention characterized by intentional wounds with minimal tissue loss, in which the edges are closely approximated. This means that the wound is clean, with little to no tissue damage, and the edges of the wound can easily be brought together for proper healing. Primary intention is often used for surgical incisions or wounds that can be easily closed with sutures or other methods to promote rapid healing and minimize scarring.

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  • 17. 

    Which type of intention is defined as having edges that are not well approximated.

    Correct Answer
    secondary
    secondary intention
    Explanation
    Secondary intention is a type of intention that is defined as having edges that are not well approximated. This means that when a wound or injury heals through secondary intention, the edges of the wound do not come together neatly or smoothly. Instead, the wound is left open to heal from the bottom up, with new tissue filling in the gap over time. This type of healing is often seen in larger or deeper wounds, where the edges cannot be easily brought together or closed with sutures or staples.

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  • 18. 

    A large or open wound, such as a burn or major trauma, left alone to heal is:

    • A.

      Primary intention

    • B.

      Delayed primary intention

    • C.

      Secondary intention

    • D.

      Tertiary intention

    • E.

      None of the above

    Correct Answer
    C. Secondary intention
    Explanation
    Secondary intention refers to the healing process of a large or open wound, such as a burn or major trauma, that is left alone to heal without surgical closure. In this process, the wound is allowed to heal naturally by granulation tissue formation, contraction, and epithelialization. This differs from primary intention where the wound edges are brought together and closed with sutures, and from delayed primary intention where the wound is initially left open but later closed surgically. Tertiary intention refers to a wound that is initially left open but is later closed surgically after a period of healing by secondary intention.

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  • 19. 

    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.

      Primary intention

    • B.

      Delayed primary intention

    • C.

      Tertiary intention

    • D.

      B and C

    • E.

      A and C

    Correct Answer
    D. B and C
    Explanation
    The correct answer is B and C. In this scenario, Mr. Griffin's wound has undergone delayed primary intention and tertiary intention healing. Delayed primary intention occurs when a wound is initially left open to heal through granulation tissue formation, and then later sutured. Tertiary intention, also known as delayed closure, involves leaving a wound open for a significant amount of time to allow for cleaning and healing of the wound bed, and then closing it with sutures. In Mr. Griffin's case, the wound was initially left open to heal on its own (delayed primary intention) and then sutured several days later (tertiary intention).

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  • 20. 

    Which phase of wound healing occurs first?

    Correct Answer
    Inflammatory Phase
    Explanation
    The first phase of wound healing is the "Inflammatory Phase," during which the body responds to the injury with inflammation. This phase aims to control bleeding, prevent infection, and initiate the healing process by recruiting immune cells and releasing growth factors to prepare the wound for repair.

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  • 21. 

    In the inflammatory phase of wound healing, this type of white blood cell arrive first to ingest bacteria and cellular debris .

    • A.

      Leukocytes

    • B.

      Macrophages

    • C.

      Fibroblasts

    • D.

      A and B

    • E.

      None of the above

    Correct Answer
    A. Leukocytes
    Explanation
    During the inflammatory phase of wound healing, leukocytes are the first type of white blood cells to arrive at the site of injury. They play a crucial role in the immune response by ingesting bacteria and cellular debris through a process called phagocytosis. This helps to eliminate pathogens and clean up the damaged tissue, preparing the wound for the next phase of healing. Macrophages, which are a type of leukocyte, also participate in this process. Therefore, the correct answer is leukocytes.

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  • 22. 

    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.

      Hemostasis

    • B.

      Inflammatory phase

    • C.

      Proliferation phase

    • D.

      A and B

    • E.

      None of the above

    Correct Answer
    A. Hemostasis
    Explanation
    During the process of hemostasis, blood vessels initially constrict to reduce blood flow and allow blood clotting to occur. This constriction helps to prevent excessive bleeding. After clot formation, the blood vessels then dilate to increase capillary permeability. This increased permeability allows plasma and blood components to leak out into the injured area, facilitating the healing process by delivering necessary nutrients and immune cells. Therefore, the correct answer is Hemostasis.

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  • 23. 

    Acute inflammation occurs in which of the phases of wound healing

    Correct Answer
    inflammatory
    inflammatory phase
    inflammation
    inflammation phase
    Explanation
    The correct answer is "inflammatory phase" or "inflammation phase". Acute inflammation is a normal response of the body to injury or infection, and it is one of the initial phases of wound healing. During this phase, blood vessels dilate, allowing increased blood flow to the injured area. This results in redness, swelling, heat, and pain. The inflammatory phase helps to remove debris, pathogens, and damaged tissue from the wound site and initiates the healing process.

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  • 24. 

    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)

    Correct Answer
    proliferation phase, fibroblastic phase, regenerative phase, connective tissue phase, proliferative phase
    Explanation
    Granulation tissue, which forms the foundation for scar tissue development, is made in the proliferation phase of wound healing. During this phase, fibroblasts migrate to the wound site and begin to synthesize collagen and other extracellular matrix components. This leads to the formation of granulation tissue, which is rich in blood vessels and provides a scaffold for new tissue growth. The proliferation phase is an important step in wound healing, as it prepares the wound for the next phase of remodeling and maturation.

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  • 25. 

    What type of tissue forms the foundation for scar tissue development

    Correct Answer
    granulation tissue, granulation
    Explanation
    Granulation tissue is a type of tissue that forms during the healing process of a wound. It is composed of new blood vessels, fibroblasts, and inflammatory cells. Granulation tissue acts as the foundation for scar tissue development by providing a scaffold for the migration of cells involved in tissue repair. As the wound heals, the granulation tissue is gradually replaced by collagen fibers, resulting in the formation of scar tissue. Therefore, granulation tissue plays a crucial role in the formation and organization of scar tissue.

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  • 26. 

    During which phase of wound healing is generalized body response most notably present?

    • A.

      Hemostasis

    • B.

      Inflammatory phase

    • C.

      Proliferation phase

    • D.

      Maturation phase

    • E.

      Fibroblastic phase

    Correct Answer
    B. Inflammatory phase
    Explanation
    During the inflammatory phase of wound healing, the body's immune response is most notably present. This phase begins immediately after injury and lasts for approximately 3-5 days. It is characterized by the release of chemical mediators, such as histamine and prostaglandins, which cause vasodilation and increased permeability of blood vessels. This allows immune cells, such as neutrophils and macrophages, to migrate to the site of injury and remove any debris or pathogens. The inflammatory phase is crucial for initiating the healing process and preparing the wound for the subsequent phases of healing.

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  • 27. 

    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.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    In wounds that heal by primary intention, epidermal cells do not seal the wound within 24 to 28 hours. The correct timeline for epidermal cell sealing is within 48 to 72 hours. Additionally, in wounds that heal by primary intention, the granulation tissue is not visible, as this type of healing involves minimal tissue loss and the wound edges are brought together, resulting in minimal scar formation.

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  • 28. 

    True or false:Desiccation is the process of drying up. Cells dehydrate and die in a dry environment. This promotes healing.

    • A.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    Desiccation is the process of drying up, but it does not promote healing. In fact, cells dehydrate and die in a dry environment, which can be detrimental to healing. Therefore, the statement that desiccation promotes healing is false.

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  • 29. 

    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.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    Repeated trauma to a wound area does not necessarily result in delayed healing or the inability to heal. While it is true that trauma can impede the healing process, it is not always the case. Factors such as the severity of the trauma, the individual's overall health, and proper wound care can also influence the healing process. Therefore, it is incorrect to claim that repeated trauma always affects wound healing as a systemic factor.

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  • 30. 

    ______ 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)

    Correct Answer
    edema, pressure
    Explanation
    Edema refers to the accumulation of fluid in the tissues, causing swelling. When edema occurs at a wound site, it can compress blood vessels and impede the flow of blood to the area. This reduced blood supply hinders the delivery of oxygen and nutrients to the tissue, thereby affecting wound healing. Similarly, pressure applied to a wound can also disrupt the blood supply, leading to insufficient oxygen and nutrient availability for tissue repair. Both edema and pressure act as local factors that interfere with the blood supply and impede wound healing.

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  • 31. 

    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.

      Infection

    • B.

      Edema

    • C.

      Desiccation

    • D.

      Maceration

    • E.

      None of the above

    Correct Answer
    A. Infection
    Explanation
    Infection is the correct answer because when the body is invaded by pathogens, the immune system needs to use a large amount of energy to fight off these invaders. This energy expenditure leaves little or no reserves for the immune system to focus on the job of repair and healing. Infection can delay or impair the wound healing process as the immune system is primarily focused on combating the infection rather than promoting tissue repair.

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  • 32. 

    Dr. Hartman has diagnosed Peter Griffin as obese because he has large amounts of subcutaneous and tissue fat. This:

    • A.

      Slows down healing because fat tissue is more prone to infection

    • B.

      Slows down healing because fat tissue has fewer blood vessels

    • C.

      Slows down healing because fat tissue is more difficult to suture

    • D.

      All of the above

    • E.

      None of the above

    Correct Answer
    D. All of the above
    Explanation
    The correct answer is "All of the above" because all three statements are true. Fat tissue is more prone to infection, as it provides a favorable environment for bacterial growth. Fat tissue has fewer blood vessels, which means that there is less blood flow to the area, resulting in slower healing. Additionally, fat tissue is more difficult to suture because it is less firm and may not hold sutures as securely as other tissues. Therefore, all of these factors contribute to slowing down healing in individuals with large amounts of subcutaneous and tissue fat.

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  • 33. 

    True or False:Oxygenation of tissues is decreased in people with anemia.

    • A.

      True

    • B.

      False

    Correct Answer
    A. True
    Explanation
    In people with anemia, there is a decrease in the number of red blood cells or a decrease in the amount of hemoglobin in the blood. Since red blood cells are responsible for carrying oxygen to the tissues, a decrease in their number or function leads to reduced oxygenation of the tissues. Therefore, the statement "Oxygenation of tissues is decreased in people with anemia" is true.

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  • 34. 

    True or False:Healing can occur despite necrotic tissue in the wound.

    • A.

      True

    • B.

      False

    • C.

      Sometimes

    Correct Answer
    B. False
    Explanation
    False. Healing cannot occur despite necrotic tissue in the wound. Necrotic tissue refers to dead or dying tissue, which can hinder the healing process. It can delay wound closure, increase the risk of infection, and prevent the formation of healthy granulation tissue. Removing the necrotic tissue through debridement is often necessary for proper wound healing to take place.

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  • 35. 

    Which of the following does not create a higher risk for infection?

    • A.

      Contamination

    • B.

      Nosocomial infections

    • C.

      Surgery of intestines

    • D.

      All of the above

    • E.

      None of the above

    Correct Answer
    E. None of the above
    Explanation
    The given options are contamination, nosocomial infections, surgery of intestines, all of the above, and none of the above. The correct answer is "None of the above." This means that all of the options listed create a higher risk for infection.

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  • 36. 

    A wound infection can lead to other complications, including ______, which is the presence of pathogenic organisms in the blood or tissues

    Correct Answer
    sepsis
    Explanation
    A wound infection can lead to sepsis, which is the presence of pathogenic organisms in the blood or tissues. Sepsis occurs when the infection spreads and causes a systemic inflammatory response throughout the body. This can lead to organ dysfunction and failure, and if left untreated, sepsis can be life-threatening. Therefore, it is important to promptly treat and manage wound infections to prevent the development of sepsis.

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  • 37. 

    Osteomyelitis is

    • A.

      The presence of pathogenic organisms in the blood or tissue

    • B.

      Bone infection

    • C.

      Infection of the intestine

    • D.

      A and B

    • E.

      None of the above

    Correct Answer
    B. Bone infection
    Explanation
    The correct answer is "bone infection" because osteomyelitis refers to the infection and inflammation of the bone and bone marrow. It is caused by pathogenic organisms entering the bone through the bloodstream, nearby tissues, or open wounds. This condition can lead to pain, swelling, and fever, and if left untreated, it can cause bone destruction and other complications. Therefore, the presence of pathogenic organisms in the blood or tissue is not a complete definition of osteomyelitis, and it is not related to the infection of the intestine.

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  • 38. 

    Hemorrhage may occur from a:

    • A.

      Slipped suture

    • B.

      Dislodged clot from sturess at the suture line or operatuve site

    • C.

      Infection

    • D.

      Erosion of a blood vessel

    • E.

      All of the above

    Correct Answer
    E. All of the above
    Explanation
    All of the options listed can potentially cause hemorrhage. A slipped suture can lead to bleeding if it fails to hold the wound together properly. A dislodged clot from stress at the suture line or operative site can result in bleeding as well. Infection can cause inflammation and damage to blood vessels, leading to hemorrhage. Lastly, erosion of a blood vessel can cause bleeding. Therefore, all of the given options can contribute to the occurrence of hemorrhage.

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  • 39. 

    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.

    Correct Answer
    fistula
    fistula formation
    Explanation
    A fistula is an abnormal passage that connects an internal organ to the outside of the body or to another internal organ. It can be intentionally created, but it is more commonly the result of an infection that has progressed into an abscess.

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  • 40. 

    A collection of infected fluid that has not drained is a

    • A.

      Dehiscence

    • B.

      Abscess

    • C.

      Evisceration

    • D.

      Fistula

    • E.

      Hemorrhage

    Correct Answer
    B. Abscess
    Explanation
    An abscess is a collection of infected fluid that has not drained. It is typically caused by a bacterial infection and can occur in various parts of the body. The infected fluid forms a pocket or cavity, causing swelling, redness, and pain in the affected area. Treatment usually involves draining the abscess and administering antibiotics to clear the infection.

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  • 41. 

    The most serious postoperative wound complication is a:

    • A.

      Fistula

    • B.

      Dehiscence

    • C.

      Evisceration

    • D.

      A and B

    • E.

      B and C

    Correct Answer
    E. B and C
    Explanation
    p. 1192

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  • 42. 

    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.

      Dehiscence

    • B.

      Evisceration

    • C.

      Fistula

    • D.

      A and B

    • E.

      None of the above

    Correct Answer
    A. Dehiscence
    Explanation
    Dehiscence refers to the partial or total separation of wound layers due to excessive stress on wounds that have not fully healed. In this condition, the muscle is typically still intact. Evisceration, on the other hand, specifically refers to the protrusion of organs through the wound opening. Fistula is a separate condition involving an abnormal connection between two body parts. Therefore, the correct answer is Dehiscence.

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  • 43. 

    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.

      True

    • B.

      False

    Correct Answer
    B. False
    Explanation
    One should not leave the patient and rush to the nurses' station if a dehiscence and evisceration of an abdominal incision occurs. This is because dehiscence and evisceration are surgical emergencies that require immediate intervention. The nurse should stay with the patient, cover the exposed organs with sterile dressings or towels, and call for assistance while waiting for the doctor to arrive. Leaving the patient unattended can lead to further complications and delay in providing necessary medical care.

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  • 44. 

    If dehiscence occurs, certain steps should be taken. The following steps are in order. However, one of them might have a mistake; please distinguish which description of the step is wrong.

    • A.

      Notify the physician

    • B.

      All of the above have mistakes

    • C.

      None of the above have mistakes

    • D.

      Obtain clean towels

    • E.

      Moisten towels with sterile 0.9% sodium chloride solution

    Correct Answer
    D. Obtain clean towels
    Explanation
    In the context of dehiscence, obtaining clean towels is not typically a recommended step. Dehiscence refers to the surgical complication where a wound or incision from surgery begins to separate or open. The steps usually involve notifying the physician or healthcare provider and taking measures to keep the wound clean and sterile, such as applying sterile dressings or sterile 0.9% sodium chloride solution, but simply obtaining clean towels is not a standard step in addressing dehiscence.

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  • 45. 

    Which of the following is not a psycholgocal effect of wounds?

    • A.

      Axiety

    • B.

      Fear

    • C.

      Pain

    • D.

      Changes in body image

    • E.

      None of the above

    Correct Answer
    E. None of the above
    Explanation
    The question asks for a psychological effect of wounds that is not listed among the options. The options provided include anxiety, fear, pain, and changes in body image. However, all of these options are indeed psychological effects of wounds. Therefore, the correct answer is "None of the above."

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  • 46. 

    A pressure ulcer is a:

    • A.

      Acute wound

    • B.

      Chronic wound

    • C.

      It depends

    • D.

      None of the above

    Correct Answer
    C. It depends
    Explanation
    A pressure ulcer can be classified as either an acute wound or a chronic wound depending on the duration and severity of the condition. Acute pressure ulcers develop quickly and are usually caused by a sudden increase in pressure on the skin. On the other hand, chronic pressure ulcers develop over a longer period of time and are often associated with prolonged pressure on the skin. Therefore, whether a pressure ulcer is acute or chronic depends on the specific circumstances and characteristics of the wound.

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  • 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.

      Exudate

    • B.

      Fistula

    • C.

      Dehiscence

    • D.

      Hemorrhage

    • E.

      None of the above

    Correct Answer
    E. None of the above
    Explanation
    The given options do not accurately describe the condition mentioned in the question. A wound with a localized area of tissue necrosis is typically referred to as an ulcer. Ulcers are characterized by the death of skin or underlying tissues, resulting in an open sore. Therefore, the correct answer is "None of the above" as none of the options provided match the given scenario.

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  • 48. 

    Which of the following is synonymous for "pressure ulcer"

    • A.

      Decubitus ulcer

    • B.

      Bedsore

    • C.

      All of the above

    • D.

      None of the above

    Correct Answer
    C. All of the above
    Explanation
    The terms "pressure ulcer," "decubitus ulcer," and "bedsore" are all used interchangeably to refer to the same medical condition. They all describe a localized injury to the skin and underlying tissue, usually occurring over a bony prominence, as a result of prolonged pressure or friction. Therefore, all of the given options are synonymous with each other and can be used to describe the same condition.

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  • 49. 

    One of the most common skin and tissue disruption is:

    • A.

      Maceration

    • B.

      Pressure ulcers

    • C.

      Bedsores

    • D.

      A and B

    • E.

      B and C

    Correct Answer
    E. B and C
    Explanation
    The correct answer is B and C. Pressure ulcers and bedsores are both common forms of skin and tissue disruption. Pressure ulcers occur due to prolonged pressure on the skin, often in individuals who are immobile or bedridden. Bedsores, also known as decubitus ulcers, develop when pressure restricts blood flow to an area of the body, leading to tissue damage. Both conditions can be painful and require proper medical attention and care to prevent complications.

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  • 50. 

    Who of the following is the most at risk for a pressure ulcer:

    • A.

      Peter Griffin, because of his obesity

    • B.

      Mayor Adam West, because of minor brain impairment

    • C.

      Joe Swanson, because he is a paraplegic

    • D.

      Stewie Griffin, because he is an infant

    • E.

      The evil monkey, because he is an evil monkey

    Correct Answer
    C. Joe Swanson, because he is a paraplegic
    Explanation
    Joe Swanson is the most at risk for a pressure ulcer because he is a paraplegic. Paraplegia is a condition that impairs or eliminates movement and sensation in the lower extremities, making it difficult for individuals to change positions or relieve pressure on certain areas of the body. This prolonged pressure can lead to the development of pressure ulcers, also known as bedsores. Obesity, minor brain impairment, being an infant, or being an evil monkey do not inherently increase the risk of pressure ulcers.

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