Skin Integrity

Question 1

avulsion

Answer 1

An avulsion involves stripping away of large parts of tissue leaving cartilage and bone exposed

Question 2

puncture

Answer 2

A puncture involves an opening of skin caused by a narrow, sharp, pointed object

Question 3

laceration

Answer 3

A laceration involves separation of skin and tissue with torn, irregular edges

Question 4

contusion

Answer 4

A contusion is an injury to soft tissue.

Question 5

what is considered a skin appendage

Answer 5

Hair, the sebaceous gland, and eccrine sweat glands are skin appendages that are formed with the enfolding of the epidermis into the dermis. NOT CT

Question 6

The nurse is preparing a care plan for a client who has recently undergone a mastectomy. Which nursing diagnosis should the nurse rank with the highest priority?

Answer 6

Impaired tissue integrity

Question 7

desiccation

Answer 7

the process of drying up. Cells dehydrate and die in the environment this delays healing

Question 8

macceration

Answer 8

over hydration result from excessive exposure to mostuire

Question 9

Dehiscence

Answer 9

is the partial or total separation of wound layers as a result of excessive stress on wounds that are not healed

Question 10

Evisceration

Answer 10

is the most serious complication of dehiscence. The wound separates completely with protrusion of viscera through the incisional area.

Question 11

A client who has a bacterial infection develops an abscess that needs to be drained. What drainage system would most likely be used in this situation?

Answer 11

Penrose

Question 12

Purpose and example of Jackson-Prattt use

Answer 12

Purpose: decreases dead space by collecting drainage
Example: after breast removal and abdominal surgery

Question 13

Purpose and example of Hemovac

Answer 13

Purpose: decreases dead space by collecting drainage
Example: after abdominal, orthopedic surgery

Question 14

Purpose and example of Penrose

Answer 14

Purpose: provide sinus tract
Example: After incision and drainage of abscess, in abdominal surgery

Question 15

The wound description reveals a beefy red wound bed that bleeds easily. What phase is that?

Answer 15

This is the proliferation stage and describes granulation tissue

Question 16

Hemostasis is

Answer 16

Hemostasis is the initial phase that involves activation of platelets.
during homeostasis the same blood vessels dilate and capillary permeability increases, allowing plasma and blood components to leak out into the area that is injured forming excudate

Question 17

The inflammatory phase involves

Answer 17

white blood cells and macrophages entering the wound to remove debris from the wound.

Question 18

The maturation phase involves

Answer 18

collagen remodeling and scar formation.

Question 19

in wounds that heal by first intention, epidermal cells seal the wound within

Answer 19

24 to 48 hours

Question 20

The nurse is caring for a client who has a deep wound and whose saline-moistened wound dressing has been changed every 12 hours. While removing the old dressing, the nurse notes that the packing material is dry and adheres to the wound bed. Which modification is most appropriate?

Answer 20

reduce time interval between dressing changes

Question 21

When performing a dressing change, the home care nurse notes that base of the client’s leg wound is red and bleeds easily. Which of the following is the appropriate action by the nurse?

Answer 21

document the findings

Question 22

functional

Answer 22

unable to make it to bathroom

Question 23

urge

Answer 23

urge to urinate may be difficult to control, leading to involuntary loss of urine
Over active bladd

Question 24

Stress

Answer 24

over distention between voiding (holding urine)

weak Pelvic muscles and structural supports, dribbling of urine during laugh/coughing/sneezing for mothers

Question 25

Over flow: chronic retention

Answer 25

involuntary loss of urine associated with over distention and overflow of bladder. Signaling of emptying the bladder may be under active or absent
may be due to a secondary effect (drug, fecal impaction, neurological condition)

Question 26

A chronic wound is one that doesn’t health within

Answer 26

4 weeks

Question 27

serous drainage

Answer 27

primary clear and watery

Question 28

sanguineous

Answer 28

large number of RBC and looks like blood

Question 29

serosanguineous

Answer 29

mixture of RBC and serum. Is light pink and blood tinged

Question 30

Purulent drainage

Answer 30

mode up of WBC, liquified dead tissue and debris, both live and dead tissue. Is thick and musty, color varies

Question 31

The nurse is caring for a client in the emergency department who cut herself 15 minutes ago while preparing dinner at her home. The nurse understands the client’s wound is in which phase of wound healing

Answer 31

hemostasis