Ch. 36

Question 1

Hematoma

Answer 1

Localized collection of blood under the tissues.

Question 2

Evisceration

Answer 2

Separation of wound layers with protrusion of visceral organs.

Question 3

Approximate

Answer 3

wound edges come together

Question 4

Abrasion

Answer 4

Superficial loss of dermis

Question 5

Shearing force

Answer 5

pressure exerted against the skin when the patient is moved.

Question 6

Cachexia

Answer 6

general poor health and malnutrition with weakness and emaciation. loss of adipose tissue.

Question 7

Debridement

Answer 7

Removal of devitalized tissue.

Question 8

Laceration

Answer 8

Torn, jagged damage to the epidermis

Question 9

Dehiscence

Answer 9

Separation of skin and tissue layers.

Question 10

Fistula

Answer 10

Abnormal passage between two body organs or between an organ and the outside of the body.

Question 11

Example of a contributing for pressure ulcer formation:

Answer 11

Shear, friction, moisture on the skin, poor nutrition, cachexia, infection, impaired peripheral circulation, obesity, advanced age.

Question 12

A clean surgical wound with little tissue loss heals by:

Answer 12

primary intention

Question 13

A severe laceration or chronic wounds heal by:

Answer 13

secondary intention

Question 14

Separation of the layers of the skin with serosanguineous drainage noted.

Answer 14

dehiscence

Question 15

Bluish swelling or mass at the site

Answer 15

hematoma/ bleeding

Question 16

Fever, general malaise, and increased white blood cell count

Answer 16

Infection

Question 17

Decreased blood pressure, increased pulse rate, increased respirations.

Answer 17

bleeding/shock

Question 18

Green, odorous local drainage

Answer 18

infection

Question 19

Visceral organs protruding through abdominal wall

Answer 19

Evisceration

Question 20

Wound edges swollen, painful, with redness, extending from the edges outward.

Answer 20

infection

Question 21

Wound drainage:Serous

Answer 21

Clear, watery plasma

Question 22

Wound drainage: Sanguineous

Answer 22

Fresh bleeding

Question 23

Wound drainage: Serosanguineous

Answer 23

Pale, more watery, with plasma and red blood cells

Question 24

Wound drainage; purulent

Answer 24

Thick, yellow, green, or brown with organisms and white blood cells

Question 25

Steps for obtaining an aerobic wound culture:

Answer 25

1. cleanse the wound and allow to dry. 2. Moisten swab with normal saline 3. Swab wound in a 1X1 cm area 4. Apply pressure to express fluid from wound onto swab. 5. Return the swab to the culture tube.

Question 26

For wound irrigation, identify the following that are considered as safe guidelines; Syringe size, needle gauge, psi?

Answer 26

syringe size:35 mL Needle gauge: 19 gauge psi: 8

Question 27

The nurse should be held how far above the wound?

Answer 27

1 in (2.5 cm) above the wound.

Question 28

During the irrigation, the nurse notes sanguineous return. The nurse should?

Answer 28

reduce the irrigating pressure and notify the health care provider.

Question 29

Identify the steps in caring for a traumatic wound:

Answer 29

1) stabilize the pt cardiopulmonary function. 2) promote hemostasis (stop any bleeding) 3) cleanse the wound 4) protect the site for further injury.

Question 30

Tissue Ischemia

Answer 30

decreased blood flow to tissue resulting in tissue death, occurs when capillary blood flow is obstructed, as in the case of pressure.

Question 31

Blanchable hyperemia

Answer 31

area that appears red and warm will blanch

Question 32

Nonblanchable hyperemia

Answer 32

is redness that persists after palpation and indicates tissue damage.

Question 33

Unstageable

Answer 33

Full-thickness tissue loss in which the base of the ulcer is covered by slough.

Question 34

A wound with little or no tissue loss such as a clean surgical incision, heals by:

Answer 34

Primary intention

Question 35

A wound involving loss of tissue such a severe laceration, heals how?

Answer 35

secondary intention

Question 36

Full thickness wound repair:

Answer 36

Hemostasis, inflammation, proliferative, remodeling.

Question 37

Hemostasis phase

Answer 37

involving a full thickness wound healing by primary intention is hemostasis, the control of bleeding.

Question 38

Inflammation phase

Answer 38

establish a clean wound bed and to obtain bacterial balance.

Question 39

Proliferative phase

Answer 39

production of new tissue, epithelialization, and contraction.

Question 40

Remodeling phase

Answer 40

last up to 1 year, reorganizes collagen to produce more elastic, stronger collagen for the scar tissue.

Question 41

Ecchymosis

Answer 41

skin discoloration, or bruising caused by blood leakage into subcutaneous tissues after trauma to underlying vessels.

Question 42

maceration

Answer 42

softening of the skin due to moisture

Question 43

Types of dressings:

Answer 43

Hydrocolloid, hydrocel

Question 44

Hydrocolloid

Answer 44

gelling agents and have adhesive wound surface.

Question 45

Hydrocel

Answer 45

available in sheets or gel in a tube. high percentage of water and are indicated for wounds that require moisture, either a wound with granulation (maintaining the moist wound environment needed for healing) or a wound that has high necrotic tissue.