Chapter 37 Skin Integrity And Wound Healing

Chapter 37  Skin Integrity And Wound Healing

Complete Chapter Questions And Answers
 

Sample Questions

MULTIPLE CHOICE

1. The client’s wound has purulent exudate. The nurse knows this exudate occurs when the client has:
a.
mild inflammation.
b.
severe inflammation.
c.
severe inflammation accompanied by infection.
d.
minimal capillary damage.

ANS: C
Purulent exudate is seen in a wound that is severely inflammed and infected. Serous exudate is seen in a wound with mild inflammation with minimal capillary damage. Hemorrhagic exudate is seen in wounds with severe inflammation.

PTS: 1 DIF: Analysis REF: Kinds of Wounds

2. The nurse is planning care for several surgical clients. Which client would most likely have the best wound healing?
a.
An older adult
b.
The client who eats a high-protein, high-carbohydrate diet
c.
The client diagnosed with anemia
d.
The client prescribed steroids

ANS: B
Nutrition affects wound healing. The client who eats a balanced diet with adequate amounts of protein and carbohydrates will most likely have the best wound healing. The very young and the elderly could have impaired wound healing because of changes in circulation, oxygenation, clotting, inflammatory response, and phagocytosis. Reduced hemoglobin levels, as in anemia, will alter wound healing by reducing the synthesis of collagen and reducing oxygen delivery to the tissues for repair. Steroids reduce the inflammatory response and suppress protein synthesis, causing wounds to heal slowly.

PTS: 1 DIF: Application REF: Table 37-1 Factors Affecting Wound Healing

3. The nurse, caring for a client recovering from abdominal surgery, realizes that the risk for postoperative hemorrhage is the greatest:
a.
during the first 24 to 48 hours after surgery.
b.
48 to 72 hours after surgery.
c.
3 days to 1 week after surgery.
d.
2 to 3 weeks after surgery.

ANS: A
The risk for hemorrhage is greatest during the first 24 to 48 hours after surgery. The risk for hemorrhage after surgery decreases after this time.

PTS: 1 DIF: Analysis REF: Factors Affecting Wound Healing

4. The client, who is 5-days postoperative, coughs hard and the wound opens and the intestines protrude through the wound. The nurse identifies this event as:
a.
dehiscence.
c.
angiogenesis.
b.
evisceration.
d.
unintentional wound.

ANS: B
Evisceration occurs when the client’s viscera protrude through a disrupted wound. Excessive coughing can cause evisceration. Dehiscence is the partial or complete separation of the wound edges and the layers below the skin. Angiogenesis is the formation of new blood vessels within a wound. An unintentional wound is an unplanned wound caused by trauma or an accident.

PTS: 1 DIF: Analysis
REF: Dehiscence and Evisceration| Wound Classification

5. The client has a red wound. How should this wound be cared for?
a.
It should be protected and kept moist and clean.
b.
It needs debridement.
c.
It needs to be cleansed of purulent exudate and nonviable slough needs to be removed.
d.
It should be left open to the air to dry.

ANS: A
Red wounds are the color of normal granulation tissue and are in the proliferative phase of wound repair. These wounds are to be protected and kept moist and clean. A black wound needs to be debrided. A yellow wound needs to be cleansed of purulent exudate and nonviable slough needs to be removed. A red wound should not be left open to the air to dry.

PTS: 1 DIF: Application REF: The RYB Wound Classification System