Chapter 35 Skin Integrity & Wound Healing

Chapter 35  Skin Integrity & Wound Healing

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. What is the function of the stratum corneum?
a)
Provides insulation for temperature regulation
b)
Provides strength and elasticity to the skin
c)
Protects the body against the entry of pathogens
d)
Continually produces new skin cells

ANS: C
The stratum corneum is the outermost layer of the epidermis and is composed of numerous thicknesses of dead cells. Functioning as a barrier to the environment, it restricts water loss, prevents entry of fluids into the body, and protects the body against the entry of pathogens and chemicals. The subcutaneous layer is composed of adipose and connective tissue that provide insulation, protection, and an energy reserve (adipose). The dermis is composed of irregular fibrous connective tissue that provides strength and elasticity to the skin. The stratum germinativum is the innermost layer of the skin that produces new cells, pushing older cells toward the skin surface.

Difficulty: Moderate
Client Need: PHSI
Cognitive Level: Comprehension

PTS: 1

2. Why might skin integrity and wound healing be compromised in the client who takes blood pressure medications? Antihypertensives:
a)
Can cause cellular toxicity
b)
Increase the risk of ischemia
c)
Delay wound healing
d)
Predispose to hematoma formation

ANS: B
Blood pressure medications decrease the amount of pressure required to occlude blood flow to an area, creating a risk for ischemia. Chemotherapeutic agents delay wound healing because of their cellular toxicity. Anticoagulants can lead to extravasation of blood into subcutaneous tissue, predisposing to hematoma formation with minimal pressure or injury.

Difficulty: Difficult
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Comprehension

PTS: 1

3. What is the primary difference between acute and chronic wounds? Chronic wounds:
a)
Are full-thickness wounds, but acute wounds are superficial
b)
Result from pressure, but acute wounds result from surgery
c)
Are usually infected, whereas acute wounds are contaminated
d)
Exceed the typical healing time, but acute wounds heal readily

ANS: D
The length of time for healing is the determining factor when classifying a wound as acute or chronic. Acute wounds are expected to be of short duration. Wounds that exceed the anticipated length of recovery are classified as chronic wounds.

Difficulty: Easy
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Analysis

PTS: 1

4. A patient with quadriplegia presents to the outpatient clinic with an ischial wound that extends through the epidermis into the dermis. When documenting the depth of the wound, how would the nurse classify it?
a)
Partial-thickness wound
b)
Penetrating wound
c)
Superficial wound
d)
Full-thickness wound

ANS: A
Partial-thickness wounds extend through the epidermis into the dermis. Superficial wounds involve only the epidermal layer of skin. Full-thickness wounds extend into the subcutaneous tissue and beyond. Penetrating is a descriptor sometimes added to indicate that the wound includes internal organs.

Difficulty: Easy
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Application

PTS: 1

5. A patient underwent abdominal surgery for a ruptured appendix. The surgeon did not surgically close the wound. The wound healing process described in this situation is:
a)
Primary intention healing
b)
Secondary intention healing
c)
Tertiary intention healing
d)
Approximation healing

ANS: B
Secondary intention healing occurs when a wound is left open, and it heals from the inner layer to the surface by filling in with beefy red granulation tissue. Primary intention healing occurs when a wound is surgically closed. Tertiary intention healing occurs when a wound that was previously left open to heal by secondary intention is closed by joining the margins of granulation tissue. Approximation is another word for the joining of wound edges.

Difficulty: Moderate
Nursing Process: Assessment
Client Need: PHSI
Cognitive Level: Comprehension

PTS: 1