Week 2

Question 1

Pressure ulcer is also known as _________.

Answer 1

Decubitus ulcer

Question 2

Localized areas of prolonged restricted blood flow of soft tissue, usually over bony areas is ___________?

Answer 2

Decubitus ulcer

Question 3

Disruptions in the integrity of the skin and underlying tissues that heal slowly with time is ___________?

Answer 3

Acute wounds

Question 4

A wound that does not heal in an orderly set of stages and in a predictable amount of time is ______________?

Answer 4

Chronic wounds

Question 5

What is the Braden Scale?

Answer 5

Score that indicates level of risk of skin breakdown

Question 6

_________________ is redness of the skin or mucous membranes, increased blood flow in superficial capillaries.

Answer 6

Erythema

Question 7

When skin is in contact with moisture for too long that is called ____________________.

Answer 7

Maceration wound

Question 8

The development of new tissue and blood vessels in a wound during the healing process is ___________.

Answer 8

Granulation

Question 9

The formation of epithelium over a wound incision is __________?

Answer 9

Epitheliazation

Question 10

_______________ consists of fluid and leukocytes that move to the site of injury from the circulatory system in response to local inflammation.

Answer 10

Exudate

Question 11

A thick and milky discharge from a wound is ___________.

Answer 11

Purulent

Question 12

__________ in wound healing refers to dead tissue, usually cream or yellow in colour.

Answer 12

Slough

Question 13

If all redness disappears when light finger pressure is applied which typically indicates a temporary obstruction of blood flow to that area is known as __________.

Answer 13

Blanching

Question 14

Hardening of the skin and subcutaneous tissues around a wound due to inflammation is ___________.

Answer 14

Induration

Question 15

________________ is a higher blood flow than normal in response to something happening in your body that increases its demand for blood.

Answer 15

Hyperemia

Question 16

When tissue dies due to various underlying causes, such as poor blood supply, infection, or trauma is ____________?

Answer 16

Necrotic

Question 17

_____________ time is a quick, reliable method for detecting changes in blood flow that can lead to shock.

Answer 17

Capillary refill

Question 18

___________ is a separation of the wound edges from the surrounding healthy tissue, often creating a “pocket” under the wound surface.

Answer 18

Undermining

Question 19

What stage of Pressure Ulcers is the following:

Intact skin with nonblanchable redness

Answer 19

Stage 1

Question 20

What stage of Pressure Ulcers is the following:

Partial-thickness skin loss involving epidermis, dermis, or both.

Answer 20

Stage 2

Question 21

What stage of Pressure Ulcers is the following:

Full-thickness tissue loss with visible fat

Answer 21

Stage 3

Question 22

What stage of Pressure Ulcers is the following:

Full-thickness tissue loss with exposed bone, muscle, or tendon

Answer 22

Stage 4

Question 23

What stage of Pressure Ulcers is the following:

Full-thickness tissue loss, in which the base of the ulcer is covered by slough or eschar in the wound bed.

Answer 23

Unstageable

Question 24

If you can’t see the wound base the wound is labeled __________ in your documentation

Answer 24

Stage X

Question 25

_________ is dead tissue that is dry, black, hard necrotic tissue

Answer 25

Eschar

Question 26

Pressure Ulcers planning goal examples:

Answer 26

-Reduction or elimination of the factors that lead to pressure ulcers
- Preventing an infection in the pressure ulcer
-Healing of pressure ulcers

Question 27

Pressure ulcer nursing interventions examples:

Answer 27

• Pressure relief
• Positioning
• Skin Care
• Nutrition (focus on protein)

Question 28

A surgical complication in which a wound ruptures along a surgical incision. __________.

Answer 28

Dehiscence

Question 29

______________ is a rare but severe surgical complication where the surgical incision opens (dehiscence) and the abdominal organs then protrude.

Answer 29

Evisceration

Question 30

A _______________ is an abnormal connection between two body parts, such as an organ or blood vessel and another structure.

Answer 30

Fistula formation

Question 31

____________ is the removal of dead (necrotic) or infected skin tissue to help a wound heal.

Answer 31

Debridement

Question 32

Types of Debridement (2)

Answer 32

Selective and unselective debridement

Question 33

Selective debridement-removal of only _________ tissue.

Answer 33

Nonviable tissue

Question 34

Nonselective-removal of both _____________________________ and may prolong healing.

Answer 34

Nonviable and viable tissue

Question 35

What does not enough moisture look like? (4)

Answer 35

• Base non glistening
• Grey in color
• Dressing sticks to base
• Some products are still dry

Question 36

What does too much moisture look like? (5)

Answer 36

• Base spongy
• Base after dressing removed - floods
• Maceration
• Dressing changed two to three times a day
• Can’t see base when using transparent film

Question 37

Nursing diagnosis for pressure injury?

Answer 37

Impaired skin integrity related to pressure over bony prominence

Question 38

_____________ removes exudates; use sterile technique with syringe and needle.

Answer 38

Irrigation

Question 39

_________________ are portable units exert a safe, constant, low-pressure vacuum to remove and collect drainage.

Answer 39

Drainage evacuation

Question 40

What dressing to use for stage I or at risk and protects from friction injury and is a barrier to bacteria?

Answer 40

Transparent Dressing (Film)

Question 41

__________________ interacts with wound fluid to provide a moist environment. Used for superficial and partial-thickness wounds.

Answer 41

Hydrocolloidal

Question 42

________________ for mildly exudating wounds, clean wounds, partial or full thickness wounds; it applies pressure and removes scabs

Answer 42

Hydrogel

Question 43

__________________ dressing is indicated for bleeding and/or exudating wounds. Absorbs large volume of exudates

Answer 43

Calcium Alginates

Question 44

___________ is the process by which the body’s leukocytes and proteolytic enzymes digest nonviable tissue and debris from the wound bed. Selective process

Answer 44

Autolytic debridement

Question 45

_________________ is the application of prescriptive topical enzymes to nonviable tissue to breakdown devitalized collagen

Answer 45

Enzymatic debridement

Question 46

_________________ is the removal of devitalized tissue by physical forces that are nonselective and maybe painful

Answer 46

Mechanical debridement

Question 47

___________________ is the removal of nonviable selective tissue by a physician or specially trained or certified wound care nurse.

Answer 47

Sharp/surgical debridement

Question 48

Mechanical debridement examples (2):

Answer 48

Wet-to-dry dressings and high pressure wound irrigation

Question 49

A _________ uses negative pressure to pull edges of wounds together.

Answer 49

Vacuum Assisted Closure Device (VAC)