Med Surg- Exam 4 - Chapter 12

Question 1

In a patient with leukocytosis with a shift to the left, what does the nurse recognize as causing this finding?

a. The complement system has been activated to enhance phagocytosis
b. Monocytes are released into the blood in larger-than-normal amounts
c. The response to cellular injury is not adequate to remove damaged tissue and promote healing
d. The demand for neutrophils causes the release of immature neutrophils from the bone marrow

Answer 1

d. The demand for neutrophils causes the release of immature neutrophils from the bone marrow

Question 2

What does the mechanism of chemotaxis accomplish?

a. Causes the transformation of monocytes into macrophages
b. Involves a pathway of chemical processes resulting in cellular lysis
c. Attracts the accumulation of neutrophils and monocytes to an area of injury
d. Slows the blood flow in a damaged area, allowing migration of leukocytes into tissue

Answer 2

c. Attracts the accumulation of neutrophils and monocytes to an area of injury

Question 3

What effect does the action of the complement system have on inflammation?

a. Modifies the inflammatory response to prevent stimulation of pain
b. Increases body temperature, resulting in destruction of microorganisms
c. Produces prostaglandins and leukotrines that increase blood flow, edema and pain
d. Increases inflammatory responses of vascular permeability, chemotaxis, and phagocytosis

Answer 3

d. Increases inflammatory responses of vascular permeability, chemotaxis, and phagocytosis

Question 4

Key interventions for treating soft tissue injury and resulting inflammation are remembered using the acronym RICE. What are the most important actions for the emergency department nurse to do for the patient with an ankle injury?

a. Reduce swelling, shine light on wound, control mobility, and elicit the history of the injury
b. Rub the wound clean, immobilize the area, cover the area protectively and exercise that leg
c. Rest with immobility, apply a cold compress, apply a compress bandage, and elevate the ankle
d. Rinse the wounded ankle, image the ankle, carry the patient, and extend the ankle with imaging

Answer 4

c. Rest with immobility, apply a cold compress, apply a compress bandage, and elevate the ankle

Question 5

What is characteristic of chronic inflammation?

a. It may last 2 to 3 weeks
b. The injurious agent persists or repeatedly injures tissue
c. Infective endocarditis is an example of chronic inflammation
d. Neutrophils are the predominant cell type at the site of inflammation

Answer 5

b. The injurious agent persists or repeatedly injures tissue

Question 6

During the healing phase of inflammation, which cells would be mostly likely to regenerate?

a. Skin
b. Neurons
c. Cardiac muscle
d. Skeletal muscle

Answer 6

a. Skin

Question 7

7. Place the following events that occur during healing by primary intention in sequential order from 1 (first) to 10 (last)
   a. Blood clots form (1)
   b. Avascular, pale, mature scar present (10)
   c. Accumulation of inflammatory debris (2)
   d. Enzymes from neutrophils digest fibrin (4)
   e. Epithelial cells migrate across wound surface (8)
   f. Fibroblasts migrate to site and secrete collagen (6)
   g. Budding capillaries result in pink, vascular friable wound (7)
   h. Contraction of healing area by movement of myofibroblasts (9)
   i. Macrophages ingest and digest cellular debris and red blood cells (3)
   j. Fibrin clot that serves as meshwork for capillary growth and epithelial cell migration (5)

Answer 7

Blood clots form (1)
Accumulation of inflammatory debris (2)
Macrophages ingest and digest cellular debris and red blood cells (3)
Enzymes from neutrophils digest fibrin (4)
Fibrin clot that serves as meshwork for capillary growth and epithelial cell migration (5)
Fibroblasts migrate to site and secrete collagen (6)
Budding capillaries result in pink, vascular friable wound (7)
Epithelial cells migrate across wound surface (8)
Contraction of healing area by movement of myofibroblasts (9)
Avascular, pale, mature scar present (10)

Question 8

8. What is the primary difference between healing by primary intention and healing by secondary intention?
   a. Secondary healing requires surgical debridement for healing to occur
   b. Primary healing involves suturing two layers of granulation tissue together
   c. Presence of more granulation tissue in secondary healing results in more scarring
   d. Healing by secondary intention takes longer because more steps in the healing process are necessary

Answer 8

c. Presence of more granulation tissue in secondary healing results in more scarring

Question 9

9. A patient had abdominal surgery 3 months ago and calls the clinic with complaints of severe abdominal pain and cramping, vomiting and bloating. What should the nurse most likely suspect as the cause of the patient’s problem?
   a. Infection
   b. Adhesion
   c. Contracture
   d. Evisceration

Answer 9

b. Adhesion

Question 10

10. A patient had a complicated vaginal hysterectomy. The student nurse provided perineal care after the patient had a bowel movement. The student nurse tells the nurse there was a lot of light brown, smelly drainage seeping from the perianal area. What should the nurse suspect when assessing the patient?
    a. Dehiscence
    b. Hemorrhage
    c. Keloid formation
    d. Fistula formation

Answer 10

d. Fistula formation

Question 11

11. Which nutrients aid in capillary synthesis and collagen production by the fibroblasts in wound healing?
    a. Fats
    b. Proteins
    c. Vitamin C
    d. Vitamin A

Answer 11

c. Vitamin C

Question 12

12. What role do the B-complex vitamins play in wound healing
    a. Decrease metabolism
    b. Protect protein from being used for energy
    c. Provide metabolic energy for the inflammatory process
    d. Coenzymes for fat, protein, and carbohydrate metabolism

Answer 12

d. Coenzymes for fat, protein, and carbohydrate metabolism

Question 13

13. The patient is admitted from home with a stage II pressure ulcer. This wound is classified as a yellow wound using a red-yellow-black concept of wound care. What is the nurse likely to observe when she does her wound assessment?
    a. Serosanguineous drainage
    b. Adherent gray necrotic tissue
    c. Clean, moist granulating tissue
    d. Creamy ivory to yellow-green exudate

Answer 13

d. Creamy ivory to yellow-green exudate

Question 14

14. What type of dressing will the nurse most likely use for the patient in question 14?
    a. Dry, sterile dressing
    b. Absorptive dressing
    c. Negative pressure wound therapy
    d. Telfa dressing with antibiotic ointment

Answer 14

b. Absorptive dressing

Question 15

15. The patient’s wound is not healing, so the health care provider is going to send the patient home with negative pressure wound therapy or a “wound vac” device. What will the caregiver need to understand about the use of this device?
    a. The wound must be cleaned daily
    b. The patient will be placed in a hyperbaric chamber
    c. The occlusive dressing must be sealed tightly to the skin
    d. The diet will not be as important with this sort of treatment

Answer 15

c. The occlusive dressing must be sealed tightly to the skin

Question 16

16. During care of patients, what is the most important precaution for preventing transmission of infections?
    a. Wearing face and eye protection during routine daily care of the patient
    b. Wearing nonsterile gloves when in contact with body fluids, excretions, and contaminated linens
    c. Wearing a gown to protect the skin and clothing during patient care activities likely to soil clothing
    d. Hand washing after touching fluids and secretions and removing gloves, as well as between patient contacts

Answer 16

d. Hand washing after touching fluids and secretions and removing gloves, as well as between patient contacts

Question 17

17. Which patient is that the greatest risk for developing pressure ulcers?
    a. A 42-year old obese woman with type 2 diabetes
    b. A 78-year old man who is confused and malnourished
    c. A 30-year old man who is comatose following a head injury
    d. A 65-year old woman who has urge and stress incontinence

Answer 17

c. A 30-year old man who is comatose following a head injury

Question 18

18. What is the most important nursing intervention for the prevention and treatment of pressure ulcers?
    a. Using pressure-reduction devices
    b. Massaging pressure areas with lotion
    c. Repositioning the patient a minimum of every 2 hours
    d. Using lift sheets and trapeze bars to facilitate patient movement

Answer 18

c. Repositioning the patient a minimum of every 2 hours

Question 19

19. The patient is transferring from another facility with the description of a sore on her a sacrum that is deep enough to see the muscle. What stage of pressure ulcer does the nurse expect to see on admission?
    a. Stage I
    b. Stage II
    c. Stage III
    d. Stage IV

Answer 19

d. Stage IV

Question 20

20. A patient’s documentation indicates he has a stage III pressure ulcer on his right hip. What should the nurse expect to find on assessment of the patient’s right hip?
    a. Exposed bone, tendon or muscle
    b. An abrasion, blister or shallow crater
    c. Deep crater through subcutaneous tissue or fascia
    d. Persistent redness (or bluish color in darker skin tones)

Answer 20

c. Deep crater through subcutaneous tissue or fascia

Question 21

21. Which nursing interventions for a patient with a stage IV sacral pressure ulcer are most appropriate to assign or delegate to a licensed practical nurse (LPN) Select all that apply
    a. Assess and document wound appearance
    b. Teach the patient pressure ulcer risk factors
    c. Choose the type of dressing to apply to the ulcer
    d. Measure the size (width, length, depth) of the ulcer
    e. Assist the patient to change positions at frequent intervals

Answer 21

d. Measure the size (width, length, depth) of the ulcer

e. Assist the patient to change positions at frequent intervals