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1523 Theory > Tissue Integrity > Flashcards

Tissue Integrity Flashcards

1
Q

A nurse is teaching a group of older adults at a community center about the functions of the skin. Which of the following statements should the nurse include in the teaching? (SATA)

a)The skin plays an important role in the production of vitamin D.
b)The dermis contains cells that help prevent infection.
c)The skin protects against bacteria and viruses.
d)The skin helps regulate the body temperature.

A

a) The skin plays an important role in the production of vitamin D.
c) The skin protects against bacteria and viruses.
d) The skin helps regulate the body temperature.

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2
Q

What are some functions of the subcutaneous layer of skin? (Select all that apply)

A. Thermoregulation
B. Waste elimination
C. Insulation and shock absorption
D. Blood supply and nerve connection

A

A. Thermoregulation
C. Insulation and shock absorption
D. Blood supply and nerve connection

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3
Q

What skin problems are neonates most likely to develop? (Select all that apply)

A. Pressure injuries
B. Diaper rash
C. Skin infections
D. Skin tears

A

A. Pressure injuries
B. Diaper rash
D. Skin tears

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4
Q

Which component of the dermis contributes to wound healing?

A. Melanocytes
B. Fibroblasts
C. Langerhans cells
D. Keratinocytes

A

B. Fibroblasts

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5
Q

How do Merkel cells function in the skin?

A. Protect against infections
B. Produce melanin
C. Detect light touch, especially in the palms and soles
D. Promote collagen production

A

C. Detect light touch, especially in the palms and soles

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6
Q

Why might clients with chronic illnesses like kidney disease or liver failure experience impaired tissue integrity?

A. Due to improved thermoregulation
B. Because these conditions enhance skin hydration
C. These conditions contribute to skin frailty, making the skin more vulnerable
D. They reduce skin elasticity, making it more resistant to injuries

A

C. These conditions contribute to skin frailty, making the skin more vulnerable

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7
Q

What should be included when documenting pressure injuries? (Select all that apply)

A. Location and size of the wound
B. Stage and description of the tissue
C. Condition of surrounding skin and presence of odor
D. Number of stitches applied

A

C. Condition of surrounding skin and presence of odor

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8
Q

Which of the following is NOT true about the Braden Scale?

A. It assesses risk for tissue integrity issues
B. It has six categories, including sensory perception and nutrition
C. A higher score indicates a higher risk of pressure injuries
D. It is used for hospitalized clients

A

C. A higher score indicates a higher risk of pressure injuries

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9
Q

Which of the following best describes a surgical wound that is classified as “clean-contaminated”?

A. A wound with minimal bacterial load, closed after surgery
B. A wound with significant bacterial contamination, requiring antibiotics
C. A wound that heals without any complications
D. A wound that is completely sterile

A

A. A wound with minimal bacterial load, closed after surgery

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10
Q

What is the correct term for a type of wound that results from a mechanical force, like removing tape from the skin?

A. Laceration
B. Skin tear
C. Abrasion
D. Puncture wound

A

B. Skin tear

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11
Q

Which agent is often used in biological debridement for clients who cannot undergo surgical debridement?

A. Collagenase
B. Silver nitrate
C. 0.9% sodium chloride
D. Betadine

A

A. Collagenase

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12
Q

Which dressing is most suitable for wounds with moderate to high exudate that require hemostasis and high absorption?

A. Hydrogel
B. Alginate
C. Film
D. Polymeric membrane

A

B. Alginate
C. Film
D. Polymeric membrane

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13
Q

What are the benefits of hydrocolloid dressings? (Select all that apply)

A. Bacteriostatic properties
B. Maintains a moist wound bed
C. Highly absorbent for large exudative wounds
D. Can be left in place for several days

A

A. Bacteriostatic properties
B. Maintains a moist wound bed
D. Can be left in place for several days

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14
Q

What should be done if a wound drain appears to be blocked or the drainage suddenly stops?

A. Remove the drain immediately
B. Call the provider and report the blockage
C. Increase the suction pressure
D. Ignore it, as it will resume on its own

A

B. Call the provider and report the blockage

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15
Q

Which type of dressing requires a secondary covering to prevent infection?

A. Hydrocolloids
B. Alginate dressings
C. Polymeric membranes
D. Transparent film dressings

A

B. Alginate dressings

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16
Q

Which antimicrobial agent can be used to manage wound infection and has anti-inflammatory properties?
A. Silver
B. Iodine
C. Honey
D. Alcohol

A

C. Honey

17
Q

Which of the following describes a benefit of using skin adhesives for wound closure?
A. Suitable for large, irregular wounds
B. Can be used over joints
C. Forms a protective waterproof layer over small, straight-edged wounds
D. Requires staples for proper adhesion

A

C. Forms a protective waterproof layer over small, straight-edged wounds

18
Q

Why might a hydrofiber dressing be preferred over an alginate dressing?

A. It has lower absorbency than alginate
B. It causes more maceration
C. It draws less fluid from wound edges, reducing maceration
D. It requires frequent changes

A

C. It draws less fluid from wound edges, reducing maceration

19
Q

How often should the portable wound bulb suction device be emptied?

A. Once a week
B. Every 8 hours or when more than half-full
C. Only when it stops working
D. Twice a day regardless of drainage amount

A

B. Every 8 hours or when more than half-full

20
Q

Which method is used to apply negative pressure wound therapy (NPWT)?

A. Gravity-based suction
B. Foam dressing covered by a semi-porous occlusive dressing with suction applied
C. Direct application of saline-soaked gauze
D. Use of an alginate dressing with external pressure

A

B. Foam dressing covered by a semi-porous occlusive dressing with suction applied

21
Q

In which phase of wound healing does granulation tissue primarily develop?

A. Hemostatic phase
B. Proliferative phase
C. Remodeling phase
D. Inflammatory phase

A

B. Proliferative phase

22
Q

What is a characteristic of wounds that heal by secondary intention?

A. The wound is closed with sutures immediately
B. Healing occurs from the bottom up, with granulation tissue filling the wound bed
C. The wound is clean and infection-free
D. Healing is quick and infection risk is low

A

B. Healing occurs from the bottom up, with granulation tissue filling the wound bed

23
Q

When should a skin assessment be conducted for a client admitted to a healthcare facility?
A. Only when the client complains of discomfort
B. Within the first 48 hours of admission
C. Immediately upon admission and regularly thereafter
D. After one week of observation

A

C. Immediately upon admission and regularly thereafter

24
Q

What are signs of a systemic infection that could indicate sepsis in a client with a wound? (Select all that apply)

A. Fever and chills
B. Nausea and vomiting
C. Increased white blood cell count
D. Normal body temperature and clear drainage

A

A. Fever and chills
B. Nausea and vomiting
C. Increased white blood cell count

1523 Theory (18 decks)

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