Exam 4 (Ch 34 Test Questions) Flashcards
1
Q
- What is the function of the stratum corneum?
1) Provides insulation for temperature regulation
2) Provides strength and elasticity to the skin
3) Protects the body against the entry of pathogens
4) Continually produces new skin cells
A
3
2
Q
- Skin integrity and wound healing are compromised in the client who takes blood pressure medications because antihypertensives:
1) Can cause cellular toxicity.
2) Increase the risk of ischemia.
3) Delay wound healing.
4) Predispose to hematoma formation.
A
2
3
Q
- What is the primary difference between acute and chronic wounds? Chronic wounds:
1) Are full-thickness wounds, but acute wounds are superficial.
2) Result from pressure, but acute wounds result from surgery.
3) Are usually infected, whereas acute wounds are contaminated.
4) Exceed the typical healing time, but acute wounds heal readily.
A
4
4
Q
- A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it?
1) Partial-thickness wound
2) Penetrating wound
3) Superficial wound
4) Full-thickness wound
A
1
5
Q
- A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is:
1) Primary intention healing.
2) Secondary intention healing.
3) Tertiary intention healing.
4) Approximation healing.
A
2
6
Q
- When teaching a patient about the healing process of an open wound after surgery, which of the following points would the nurse make?
1) The patient will need to take antibiotics until the wound is completely healed.
2) Because the patient’s wound was left open, the wound will likely become infected.
3) The patient will have more scar tissue formation than for a wound closed at surgery.
4) The patient should expect to remain hospitalized until complete wound healing occurs.
A
3
7
Q
- What is the primary goal that the nurse should establish for a patient with an open wound?
1) The wound will remain free of infection throughout the healing process.
2) Client completes antibiotic treatment as ordered.
3) The wound will remain free of scar tissue at healing.
4) Client increases caloric intake throughout the healing process.
A
1
8
Q
- While assessing a new wound, the nurse notes red, watery drainage. What type of drainage will the nurse document this as?
1) Sanguineous
2) Serosanguineous
3) Serous
4) Purosanguineous
A
2
9
Q
- Three days ago a patient had cardiac surgery to bypass three occlusions of his coronary arteries. Veins for the bypass were harvested from his right leg. He informs the nurse that his leg is warm and tender in his right calf. The nurse notes a 3-cm periwound erythema and swelling at the distal end of the incision. Staples are intact along the incision, and there is no drainage. Vital signs are stable. The nurse would suspect that the patient has what kind of complication?
1) Deep vein thrombosis
2) Dehiscence of the wound
3) Internal bleeding
4) Infection at the incisional site
A
1
10
Q
- Which of the following describes the difference between dehiscence and evisceration?
1) With dehiscence, there is a separation of one or more layers of wound tissue; evisceration involves the protrusion of internal viscera from the incision site.
2) Dehiscence is an urgent complication that requires surgery as soon as possible; evisceration is not as urgent.
3) Dehiscence involves the protrusion of internal viscera from the incision site; with evisceration, there is a separation of one or more layers of wound tissue.
4) Dehiscence involves rupture of subcutaneous tissue; evisceration involves damage to dermal tissue.
A
1
11
Q
- The nurse will know that the plan of care for the diabetic client with severe peripheral neuropathy is effective if the client
1) begins an aggressive exercise program.
2) follows a diet plan of 1,000 calories per day.
3) is fitted for deep-depth diabetic footwear.
4) remains free of foot wounds.
A
4
12
Q
- Pressure ulcers are directly caused by which of the following conditions at the site?
1) Compromised blood flow
2) Edema
3) Shearing forces
4) Inadequate venous return
A
1
13
Q
- A patient hospitalized in a long-term rehabilitation facility is immobile and requires mechanical ventilation with a tracheostomy. She has a pressure area on her coccyx measuring 5 cm by 3 cm. The area is covered with 100% eschar. What would the nurse identify this as?
1) Stage II pressure ulcer
2) Stage III pressure ulcer
3) Stage IV pressure ulcer
4) Unstageable pressure ulcer
A
4
14
Q
- A client developed a stage IV pressure ulcer to his sacrum 6 weeks ago, and now the ulcer appears to be a shallow crater involving only partial skin loss. What would the nurse now classify the pressure ulcer as?
1) Stage I pressure ulcer, healing
2) Stage II pressure ulcer, healing
3) Stage III pressure ulcer, healing
4) Stage IV pressure ulcer, healing
A
4
15
Q
- A patient has underlying cardiac disease and requires careful monitoring of his fluid balance. He also has a draining wound. Which of the following methods for evaluating his wound drainage would be most appropriate for assessing fluid loss?
1) Draw a circle around the area of drainage on a dressing.
2) Classify drainage as less or more than the previous drainage.
3) Weigh the patient at the same time each day on the same scale.
4) Weigh dressings before they are applied and after they are removed.
A
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