Skin Integrity and Wound Care

Question 1

True or False.
Blood vessels in the skin dilate to dissipate heat.

Answer 1

True

Question 2

_____ and _____ skin and mucous membranes defend against harmful agents.

Answer 2

Unbroken, healthy

Question 3

____ to injury is affected by age, amount of underlying tissues, and illness.

Answer 3

Resistance

Question 4

Adequately _____ and _____ body cells are resistant to injury.

Answer 4

Nourished, hydrated

Question 5

Adequate _____ is necessary to maintain cell life.

Answer 5

circulation

Question 6

In children younger than 2 years, the skin is _____ and _____ than it is in adults.

Answer 6

Thinner, weaker

Question 7

_____ and _____ formation are impaired leading to decreased elasticity and increased risk of tissue damage from pressure.

Answer 7

Circulation, collagen

Question 8

What type of wound is caused by a blunt instrument that causes injury to underlying soft tissue with the overlying skin remaining intact?
A) Contusion
B) Abrasion
C) Laceration
D) Avulsion

Answer 8

Contusion

Question 9

What are the phases of wound healing?

Answer 9

Hemostasis
Inflammation
Proliferation
Maturation

Question 10

In which phase of wound healing is the new tissue built to fill the wound space, primarily, through the action of fibroblasts?
A) Hemostasis
B) Inflammatory Phase
C) Proliferation Phase
D) Maturation Phase

Answer 10

Proliferation Phase

Question 11

Occurs immediately after the initial injury.

Answer 11

Hemostasis

Question 12

Involved blood vessels constrict and blood clotting begins.

Answer 12

Hemostasis

Question 13

Exudate is formed, causing swelling and pain.

Answer 13

Hemostasis.

Question 14

Increased perfusion results in heat and redness.

Answer 14

Hemostasis

Question 15

Platelets stimulate other cells to migrate to the injury to participate in other phases of healing.

Answer 15

Hemostasis

Question 16

Follows hemostasis and lasts about 2 to 3 days.

Answer 16

Inflammatory Stage

Question 17

White blood cells, predominantly leukocytes and macrophages, move to the wound.

Answer 17

Inflammatory Phase

Question 18

Macrophages enter the wound area and remain for an extended period.

Answer 18

Inflammatory Phase

Question 19

Macrophages ingest debris and release growth factors that attract fibroblasts to fill in the wound.

Answer 19

Inflammatory Phase

Question 20

Capillaries grow across the wound.

Answer 20

Proliferation Phase

Question 21

A thin layer of epithelial cells forms across the wound.

Answer 21

Proliferation Phase

Question 22

Granulation tissue forms a foundation for scar tissue development.

Answer 22

Proliferation Phase

Question 23

The final stage of healing begins around 3 weeks after the injury, possibly continuing for months or years.

Answer 23

Maturation Phase.

Question 24

Which wound complication is caused by overhydration related to urinary and fecal incontinence?
A) Necrosis
B) Edema
C) Desiccation
D) Maceration

Answer 24

Maceration

Question 25

Nonblanchable erythema of intact skin.

Answer 25

Stage 1

Question 26

Partial-thickness skin loss with exposed dermis.

Answer 26

Stage 2

Question 27

Full-thickness skin loss; not involving underlying fascia.

Answer 27

Stage 3

Question 28

Full-thickness skin and tissue loss

Answer 28

Stage 4

Question 29

Obscured full-thickness skin and tissue loss

Answer 29

Unstageable

Question 30

Persistent nonblanchable deep red, maroon, or purple discoloration

Answer 30

Deep tissue pressure injury

Question 31

True or False
A stage 3 pressure injury requires debridement through wet-to-dry dressings, surgical interventions, or proteolytic enzymes.

Answer 31

True